Columbia  ?Hniber2!itp  n^o^ 
in  tfje  €\tp  of  ^to  |9orfe 

CoQese  of  $t)ps>i£tans(  anb  S>urseotu( 


l^eference  Hibrarp 


LIBRAKY    OF 
AMERICAN  MEDICAL  ASSOCIATION 


PJ      >» 


FOR  THE 


^ettmb  Eftfttnn.  SnlargpJi  anii  ?SfulHpJ>. 


IRicbolas  Senn,  /IB.®.,   IPb.D,,    %%,B.,  C./IR. 

PHOFESSOE  OF  SUEGEEY,  EUSH  MEDICAL  COL- 
LEGE, IN  AFFILIATION  WITH  THE  UNIVEESITY 
OF  CHICAGO  ;  SUBGBON-IN-CHIEF,  ST.  JOSEPH'S 
HOSPITAL  ;  ATTENDING  SUEGEON  TO  THE 
PEESBYTEEIAN  HOSPITAL  ;  PEOFESSOEIAL  LEC- 
TUEEE  ON  MILITAEY  SURGERY,  UNIVEESITY 
OF  CHICAGO  ;  CHIEF  OF  THE  OPERATING 
STAFF  WITH  THE  ARMY  IN  THB  FIELD  DUE- 
ING  THE  SPANISH-AMERICAN  WAR  ;  SURGEON- 
GENERAL        OF       THE        STATE      OF        ILLINOIS. 


CublisbeD  un&er  tbe  Mrectfon  of  tbe  Sisters 

ot  Cbatltg,  St.  5osepb's  Ibospital, 

360  (SarficlD  Bv.,  Cbicago 


W.  T.  Keener  &  Co.    ::    ::    Chicago,  111. 

Number         Ninety  IT  a  b  a  -s  h         A  v  e  n  u  c 


COPYRIGHT,   1905,   BY  THE 

SISTERS  OF  CHARITY  OF  ST.   JOSEPH'S   HOSPITAL, 

360  GARFIELD  AVENUE,  CHICAGO. 


Y\.\..% 


PREFACE  TO  SECOND  EDITION. 


The  rapid  sale  of  the  first  edition  and  the  favorable 
comments  of  the  medical  press  have  shown  that  this  lit- 
tle book  has  found  a  legitimate  place  in  the  literature  on 
nursing. 

"^  The  scope  of  the  book  has  been  enlarged,  the  text 
greatly  increased,  and  many  new  illustrations  have  been 
added. 

The  author  bespeaks  for  the  second  enlarged  edition 
the  same  favorable  reception  as  was  accorded  the  first. 

N.  Senn. 

Chicago,  March,  1905. 


PREFACE  TO  FIRST  EDITION. 


This  little  book  is  intended  to  serve  as  an  aid  to  the 
trained  nnrse  in  lier  work  in  the  operating  room.  The 
text  is  made  up  largely  of  abstracts  of  lectures  delivered 
by  the  Author  to  the  pupils  of  the  Training  School  of 
St.  Joseph's  Hospital,  Chicago. 

The  principal  aim  of  this  "Guide"  is  to  instruct  the 
nurse  in  as  concise  and  thorough  a  manner  as  possible 
in  the  details  of  her  responsible  duties  before,  during, 
and  after  operations.  The  technique  of  asepsis  is  given 
a  prominence  commensurate  with  the  importance  of  the 
subject.  The  most  important  wound  complications  are 
mentioned  and  briefly  described,  so  that,  the  nurse  may 
recognize  them  and  give  timelj^  warning  to  the  attend- 
ing surgeon.  Formulee  for  the  most  reliable  antiseptic 
solutions  in  common  use  are  given.  In  giving  the  direc- 
tions for  preparation  for  the  most  important  major  op- 
erations, a  list  of  instruments  is  given  and  ligature, 
suture  and  dressing  material  are  described. 

It  has  been  deemed  advisable  to  append  illustrations 
of  instruments  in  general  use,  so  as  to  familiarize  the 
nurse  with  their  names  and  use. 

N.  Senn. 

Chicago,  April,  1902. 


CONTENTS 


CHAPTER  I. 

FAQE 

The  Surgical  Nurse 13 

CHAPTER  II. 

Preparation  of  Operating  Room  in  a  Private  House 24 

CHAPTER  111. 

Prevention  and  Treatment  of  Hemorrhage 30 

Elastic    Constriction    30 

Ligation  of  Blood  Vessels 31 

Aseptic  Tampon   32 

Hot   Saline    Solution 32 

Indirect  Ligature    32 

CHAPTER  IV. 

The  Uses  of  Normal  Salt  Solution  in  Surgery 33 

Intravenous  Infusion  33 

Subcutaneous    Injection    35 

Rectal  Enema    •. 30 

CHAPTER  V. 

Urinalysis   39 

Normal  Urine    40 

Blood  and  Pus 42 

Test  for  Albumin  42 

Test    for    Sugar 42 

Use  and  Care  of  Catheters 43 

CHAPTER  VI. 

Clinical  Thermometry   46 

CHAPTER  VII. 

Metric  Data    50 

Antiseptic  Solutions  in  Most  Common  Use 53 

Antiseptic  Powders    59 

Antiseptic  Ointments    60 

Credfi's  Unguentum    61 


10  C  0  N  T  V.  N  T  S 

CHAPTER  VIII. 

PAGE 

Preparation  for  Major  and  .Alinor  Operations 62 

Hand   Disinfection    ■ 62 

Use  and  Care  of  Rubber  (Moves 64 

Repair  of  Toi'n  and  Punctured  Rubber  Oloves 65 

Disinfection   (if   Field  of  Operation 66 

CHAPTER  IX. 

Sterilization  and  Disinfection 70 

Spores    72 

Sterilization  of  Dressing 72 

Aseptic  Adhesive   Plaster   Strips 73 

Sterilization  of  Instruments 74 

Preparation   of  Medicated   Dressing   Material 75 

Preparation  of  Waxed  or  Paraffin  Paper 77 

Drainage  and  Drainage  ^Nfaterial 78 

Cigarette   Drain    78 

Surface  Drain    79 

CHAPTER  X. 

Pre])aration  of  l^igature  and  Suture  jMaterials 80 

CHAPTER  XI. 

Ceneral  Anesthesia    84 

Ijocal  Anesthesia 99 

Spinal  Anesthesia   10.3 

CHAPTER  XII. 

Preparation   of  Patient    tor   l^ajiarotomy 104 

CHAPTER  XIII. 

After-treatment   for    {laparotomy    Patients 109 

Diel 110 

^\'oun(l  Complications,   Shock,   Hemorrhage,  Etc Ill 

Peritonitis     112 

Septicemia    114 

Sapremia 114 

Pyemia ]  l.'^ 


CONTENTS  11 

CHAPTER  XIV. 

PAGE 

Instruments,   Suturing   Material   and  Dressings   Required 

in  Surgical  Operations 116 

Gastro-enterostomy    116 

Gastrostomy    118 

Gastrectomy    118 

Ileocolostomy    119 

Inguinal    Colostomy     119 

Herniotomy    120 

Appendectomy     121 

Cholecystenterostomy    123 

Cholecystotomy     124 

Cholecystostomy    124 

Cholecystectomy    124 

CHAPTER  XV. 

Gynecologic   Operations    126 

Uterine    Curettage    12G 

Perineorrhaphy    and   Trachelorrhaphy 129 

Colporrhaphy    131 

*          Vaginal  Hysterectomy    132 

Oophorectomy  or  Salpingo- Oophorectomy 133 

Hysteropexy  133 

Abdominal  Hysterectomy  or  Hysteromyomectomy .  .  .  .  135 

Myomectomy   136 

Cesarean  Operation   136 

Obstetric  Notes   138 

CHAPTER  XVI. 

Opening  of   an  Abscess 140 

Operation  for  Harelip 141 

Cheiloplasty  141 

Staphylorrhaphy     141 

Rhinoplasty    142 

Tracheotomy    144 

Adenectomy    146 

Mammectomy   147 

Nephropexy    148 

Nephrectomy   149 

Varicotomy    149 

Dermatoplasty — Skin  Grafting 151 


12  CONTENTS 

PAGE 

Lithotomy  by  Perineal  Section 152 

Suprapubic   Lithotomy    155 

Prostatectomy   156 

Oi)eration  for  Phimosis 156 

Varicocele    156 

Rectal  Fistula   157 

Operation  for  Hemorrlioids  by  the  Use  of  the  Clamp  and 

Cautery  158 

CHAPTER  XVII. 

Operations   on  Bones  and  Joints 162 

Craniectomy    162 

Excision  of  Maxilla 164 

Resection  of  Rib   for   Empyema 167 

Sequestrotomy     168 

Amputation    of    Leg 171 

Resection  of  Joints 175 

Arthrectomy    175 

Tapping  and  Intra-articular  Medication  of  Joints.  .  .  .  175 

CHAPTER  XVIII. 

Plaster-of-Paris  Dressing   177 

Senn's  Fixation  Splint  for  Fracture  of  Neck  of  Femur.  ...    179 
Sayre's   Jacket    180 

CHAPTER  XIX. 

Surgical  Instruments    182 

Care  of  Instruments  After  Operation 183 

Important  Test  Questions    I97 


CHAPTER  I. 


THE  SURGICAL   NURSE. 

In  the  exliimied  part  of  Pompeii  stand,  as  one  of  the 
most  interesting  landmarks  of  the  former  famous  city, 
the  remains  of  the  venerable  Temple  of  ^scnlapius, 
the  fabled  god  of  the  art  of  healing.  With  the  ill-fated 
eit}^,  the  temple  was  buried  under  the  ashes  and  pumice 
stone  which  issued  in  hot  streams  from  the  angry  crater 
of  the  enraged  Vesuvius  during  that  awful  night,  ISTo- 
vember  third,  in  the  year  A.  D.  79. 

For  nearly  two  thousand  years  this  ancient  temple 
has  been  shut  out  from  the  eyes  of  the  world.  Its  altar 
has  received  no  offerings;  its  magnificent  halls  had 
4)een  silent  and  in  utter  darkness  until  they  were  re- 
cently opened  to  a  new  world,  a  new  people,  as  sacred 
and  interesting  objects  of  antiquarian  and  historical 
study.  The  priests  and  worshipers  have  disappeared 
from  the  scene;  their  places  have  been  taken  by  an  idle, 
curious,  gossiping  crowd,  with  guide  books  in  their 
hands. 

Those  who  did  duty  in  this  sacred  place,  and  those 
who  were  in  search  of  health  and  relief  from  pain  on 
that  afternoon,  when  the  infuriated  volcano  began 
his  deadly  work,  shared  the  fate  of  the  other  inhabi- 
tants of  the  unfortunate  city.  They  either  fled  in  haste 
for  a  place  of  safety,  or  were  entombed  in  the  sepulchre 
of  fire  and  smoke.  Fortunately  time  and  the  destruc- 
tive elements  have  dealt  gently  with  this  wonderful 
temple  and  its  precious  contents. 

In  the  center  of  the  capacious  ante-room  stands  the 
sacred  altar  of  pure  white  marble,  beautifully  and  artis- 
tically carved,  at  which  the  disciples  of  ^sculapius 
served  in  the  interests  of  suffering  humanity.     The  ap- 


14  A      X  U  R  S  E  '  S      GUIDE 

pearance  of  this  altar  indicates  that  it  was  used  for  a 
long  time  before  the  worship  in  the  temple  was  so  sud- 
denly interrupted  by  the  murderous  elements,  which  the 
volcano,  in  a  sudden  an«r\'  passion,  directed  towards 
the  doomed  citj^ 

This  temple  is  a  type  of  the  earh',  primitive  hospital. 
Its  altar,  its  halls,  its  roof,  were  devoted  to  works  of 
mercy  and  charity.  It  is  here  that  the  sick,  the  maimed, 
the  injured,  and  the  mad,  sought  relief.  As  I  stood  be- 
hind the  altar  where  so  many  devoted  disciples  of  ^s- 
culapius  had  ministered,  it  seemed  to  me  that  I  could 
hear  the  pitiable  appeals  of  the  suffering  Pompeians, 
and  the  sick,  who  had  come  here  from  afar,  in  a  last 
effort  to  be  healed;  and  the  sweet  words  of  consolation 
and  encouragement  of  the  officiating  priests,  engaged 
in  earnest  prayer  for  the  bodily  well-being  of  their 
supplicating  clients. 

The  modern  hospitals  are  the  new  temples  of  ^^s- 
culapius;  the  physicians  are  the  priests,  and  the  trained 
nurses  the  priestesses.  The  altars  and  the  sacrifices  have 
disappeared,  but  the  same  spirit  of  unselfishness,  char- 
ity, humanity  and  devotion  remains,  which  continues 
to  inspire  and  actuate  the  hearts  and  dictate  the  deeds 
of  those  who  are  engaged  in  the  noble  work  of  bring- 
ing sunshine  into  the  homes  darkened  by  the  shadows 
of  disease  and  death. 

There  is  no  nobler  calling  than  that  which  has  for  its 
objects  the  prevention  of  disease  and  the  care  of  the 
sick  and  disabled.  There  is  no  better  indication  of  the 
degree  of  civilization  of  any  nation  than  the  character 
of  the  institutions  devoted  to  the  care  of  the  sick  and 
the  poor.  There  is  no  profession  that  dispenses  charity 
more  freely  and  willingly  than  the  profession  of  medi- 
cine and  the  one  so  closely  allied  to  it,  the  profession 
of  nursing. 

Of  the  three  great  virtues — faith,  hope  and  charity — 
charity  is  the  greatest,  and  charity  in  its  highest,  noblest 


FOR      THE      OPERATING      ROOM.  15 

sense  is  what,  characterizes  the  daily  work  of  the  true 
physician  and  the  faithful  nurse. 

The  evolution  of  hospital  construction  has  kept 
abreast  with  the  revolutionary  progress  of  the  science 
and  art  of  medicine  during  the  last  quarter  of  a  cen- 
tury. Modern  medicine  and  surgery  have  created  a 
wide  field  for  skillful,  scientific  nursing.  The  trained 
nurse  has  become  a  necessity  to  the  physician  and  the 
right  arm  of  the  surgeon.  It  is  the  trained  nurse  who 
is  in  constant  touch  with  the  patient  and  observes  and 
records  the  progress  of  the  disease  and  carries  out  the 
orders  of  the  attending  physician.  It  is  the  trained 
records  the  progress  of  the  disease  and  carries  out  the 
necessary  preparations  for  an  operation  and  in  con- 
ducting the  after-treatment. 

The  improved  results  in  the  treatment  of  disease  and 
the  low  mortality  in  operative  work  at  the  present  day 
are  due  to  the  progress  which  the  art  and  science  of 
•medicine  have  undergone  during  the  last  twenty-five 
years,  and  the  co-operation  between  the  physician  and 
surgeon  and  the  growing  army  of  trained  nurses. 

Nursing  is  woman's  special  sphere.  It  is  her  natural 
calling.  She  is  born  a  nurse.  She  is  endowed  with  all 
the  qualifications,  mental  and  physical,  to  take  care  of 
and  comfort  the  sick.  Her  sweet  smile  and  gentle  touch 
are  often  of  more  benefit  to  the  sufferer  than  the  medi- 
cine she  administers.  The  dainty  dishes  she  knows  how 
to  prepare,  as  a  rule,  accomplish  more  in  the  successful 
treatment  of  disease  than  drugs.  Her  sense  of  duty 
and  devotion  to  those  placed  under  her  charge  are  sel- 
dom equaled  by  men.  This  became  more  apparent  to 
me  during  the  late  Spanish- American  war  than  ever 
before.  The  same  impressions  were  made  upon  me  in 
comparing  the  work  of  the  Sanitary  Corps  and  the 
trained  female  nurses  during  the  Graeco-Turkish  war. 

The  sick  or  wounded  soldier,  far  away  from  home, 
relatives  and  friends,  realizes  keenly  the  superiority  of 
the  female  over  the  male  nurse,  and  especially  is  this 


16  A    nurse's    guide 

the  ease  if  his  illness  be  tinged  with  homesickness.  It 
is  under  such  circumstances  that  the  professional  female 
nurse  is  greeted  in  camp  and  field,  on  board  ship  and  in 
the  hospital  as  an  angel  of  mercy,  and  every  look  and 
move  she  makes  are  of  the  keenest  interest  to  the  ex- 
pectant sick.  For  the  time  being  she  takes  at  the  bed- 
side the  place  of  the  devoted  wife,  the  loving  mother  or 
the  dear  sister.  She  watches  the  progress  of  the  disease 
by  day  and  throughout  the  long  nights,  and  her  heart 
rises  and  gladdens  with  the  approach  of  symptoms 
which  denote  improvement,  while  deep  sorrow  and 
tender  sjTupathy  take  possession  of  her  soul  when  the 
shadows  of  death  lengthen,  despite  her  heroic  efforts  in 
battling  with  an  unconquerable  disease  or  a  mortal 
woimd. 

Xever  does  the  trained  female  nurse  appear  grander 
and  nobler  than  when  ministering  to  the  sick  and  dying 
of  an  army  in  active  warfare. 

The  American  woman,  above  any  other,  is  peculiarly 
fitted  for  such  a  trying  and  onerous  post  of  duty.  She 
is  enthusiastic,  energetic,  tireless,  devoted  and,  more 
than  all,  intensely  patriotic. 

The  profession  of  nursing  is  following  very  closely 
the  footsteps  of  civilization  to  the  remotest  parts  of  the 
world.  The  presence  of  the  educated  female  nurse  in 
hospitals  and  communities  is  almost  a  sure  indication 
that  the  patients  she  serves  are  under  the  care  of  pro- 
gressive medical  men. 

In  the  operating  room  the  surgical  nurse  has  become 
a  necessity.  It  is  the  surgical  nurse  and  the  appliances 
for  asepsis  that  must  be  credited  to  a  large  extent  with 
having  minimized  the  complications  of  postoperative 
and  accidental  wounds.  There  are  specialties  in  nurs- 
ing as  there  are  specialties  in  medicine  and  sur- 
gery. The  successful  specialist  must  begin  his  pro- 
fessional career  as  a  competent  general  practitioner, 
from  which  position  he  elevates  liimsolf  in  tlio  direction 
for  which  he  has  a  special  aptitude.     So  the  surgical 


P  0  K      THE      0  P  E  K  A  T  I  X  G      K  0  0  M.  17 

nurse  is  recruited  from  the  ranks  of  general  nurses  in 
virtue  of  a  special  aptitude  for  surgical  work.  Every 
woman  is  in  jDossession  of  some  of  the  qualities  requisite 
for  nursing,  but  the  aptitude  for  such  a  calling  varies 
greatly  in  degree.  With  some  women  nursing  is  a  nat- 
ural vocation.  They  are  born  nurses.  They  have  in- 
herited a  natural  aptitude  for  the  care  of  the  sick. 
Their  inborn  gentleness,  good  judgment,  patience,  per- 
severance and  devotion  to  their  work  are  such  that, 
with  very  little  training,  they  become  reliable  and  com- 
petent nurses.  From  what  I  have  seen  of  the  profession 
of  nursing  in  various  parts  of  the  world  I  have  come 
to  the  conclusion  that  this  class  of  nurses  is  rather  the 
exception  tlian  the  rule. 

More  frequently  the  desirable  qualities  of  a  nurse 
have  to  be  improved  by  hard  study  and  careful  training 
before  she  has  acquired  the  necessary  qualifications  for 
the  sick  room.  I  need  not  say  that  many  of  our  gradu- 
ate female  nurses  have  made  a  serious  mistake  in  the 
choice  of  their  vocation  in  life,  as  no  amount  of  study, 
training  and  experience  can  make  up  for  the  lack  of 
those  qualifications  so  desirable  and  essential  in  a  good 
nurse.  The  surgical  nurse  is  called  upon  to  perform 
the  most  responsible  and  the  most  important  functions 
pertaining  to  the  profession  of  nursing,  and  for  tliis 
reason  alone,  if  for  no  other,  she  must  be  in  possession 
of  superior  intelligence,  tact  and  good  judgment  far 
above  the  average  general  nurse. 

It  will  not  be  amiss  to  emphasize  a  few  of  the  most 
important  qualities  which  the  surgical  nurse  should 
possess. 

Physically  she  must  have  the  strength  and  power  of 
endurance  which  her  exacting  and  often  onerous  duties 
demand.  Her  special  senses  should  be  intact,  as  all  of 
them  will  often  be  severely  taxed  in  the  daily  routine 
of  her  Avork.  Her  preliminary  education  must  be  above 
the  general  average  to  prepare  her  adequately  for  her 
professional  studies  and  the  minutiae  of  surgical  train- 


18  A      NURSES      GUIDE 

ing.  She  must  be  endowed  with  no  ordinary  degree  of 
common  sense  and  good  judgment,  without  which  all 
her  knowledge  will  often  fail  her,  in  cases  where  prompt 
action  on  her  part  may  be  the  means  of  saving  life, 
whereas  hesitation  and  uncertainty  may  prove  disas- 
trous. Deep  knowledge  and  a  well-balanced  mind  beget 
moral  courage  and  steady  hands.  Superficial  knowledge 
and  a  high-strung  nervous  temperament  are  at  the  bot- 
tom of  indecisive  and  uncertain  action.  A  good  memory 
is  indispensable — forgetfulness,  dangerous.  A  keen 
foresight  prevents  many  bitter  after-thoughts  and 
agonizing  regrets. 

Punctuality  is  an  essential  quality  of  a  reliable  sur- 
gical nurse.  The  punctual  nurse  is  present  at  the  ex- 
pected time,  has  the  preparations  for  an  operation  com- 
pleted at  the  hour  fised  by  the  operator ;  is  to  be  found 
at  her  post  when  the  surgeon  makes  his  visits,  adminis- 
ters the  medicines  and  nourishment,  takes  the  tempera- 
ture and  records  her  observations  with  the  regularity  of 
a  clock. 

Eeliability  is  another  feature  absolutely  necessary  in 
the  make-up  of  the  many  good  qualities  which  a  trained 
surgical  nurse  should  possess.  Unless  a  nurse  is  reliable 
she  can  not  be  trusted.  It  is  the  reliable  nurse  in  whom 
the  surgeon  has  full  confidence.  Should  she  make  a 
mistake,  she  has  the  moral  courage  to  acknowledge  it  to 
the  surgeon,  who  will  respect  her  for  her  candid,  honest 
conduct.  Her  bedside  records  must  bear  the  same  stamp 
of  reliability. 

The  reliable  surgical  nurse  is  always  in  readiness 
and  prepared  when  her  services  are  needed.  She  per- 
forms her  work  with  forethought,  systematical! v.  In 
making  the  antiseptic  solutions  and  in  administering 
powerful  drugs  she  never  omits  to  carefully  inspect  the 
labels  so  as  not  to  commit  serious,  if  not  fatal,  mis- 
takes. 

The  experienced  surgical  nurse  has  become  fully 
aware  of  the  uncertnintv  of  diasrnosis  in  manv  sursrical 


P  0  11      THE      OPERATING      ROOM.  19 

cases,  and,  therefore,  in  making  preparations  for  a  cer- 
tain operation  uses  her  foresight  and  is  prepared  when, 
during  the  course  of  an  operation,  conditions  are 
revealed  for  the  removS,!  or  correction  of  which,  addi- 
tional instruments  might  be  required. 

During  an  operation  the  surgical  nurse  not  only  takes 
her  legitimate  part  in  handling  the  instruments,  liga- 
ture and  suture  material,  but  watches  every  move  of  the 
operator  and  assistants,  and  if  anything  occurs  that 
might  frustrate  her  aseptic  precautions  she  removes  the 
contaminated  instrument,  suture  or  ligature,  or  silently 
places  a  basin  containing  an  antiseptic  solution  in  a 
position  where  the  guilty  party  can  not  escape  it.  Such 
prompt,  silent  action  speaks  stronger  than  words  and  is 
less  objectionable  to  those  who,  during  the  strain  of  an 
operation,  may  have  been  unconscious  of  an  act  of 
omission  or  commission  in  the  employment  of  aseptic 
precautions. 

k  In  critical  operations  the  deliberate,  cool-headed 
nurse  is  a  source  of  indescribable  comfort  to  the  sur- 
geon, and  her  prompt  actions  and  silent  suggestions  are 
not  infrequently  the  turning  point  from  an  apparent 
defeat  to  a  crowning  victory.  The  soldiers  who  have 
been  in  the  heat  of  many  battles  and  who  have  done 
most  in  thinning  out  the  lines  of  the  enemy  never  speak 
of  their  deeds  of  heroism;  and  so  the  nurse  who  has 
done  such  signal  service  never  speaks  of  her  work  boast- 
ingly,  but  is  content  with  the  consciousness  of  having 
done  her  duty. 

In  private  practice  the  surgical  nurse  must  be  re- 
sourceful. She  must  know  how  to  convert  a  kitchen, 
dining  or  living  room  into  an  aseptic  operating  room 
in  the  shortest  possible  time  and  by  the  simplest  and 
safest  means. 

In  emergency  cases,  in  the  absence  of  aseptic  dressing 
material,  she  must  be  conversant  with  procedures,  the 
employment  of  which  will,  in  a  short  time,  furnish  safe 
and  efficient  substitutes  from  m'/'tcrials  which  arc  to  be 


20  A      X  U  R  S  E  '  S      GUIDE 

foimd  in  any  household.  She  must  know  how  to  extem- 
porize an  operating  table  and  to  make  kitchen  and  table- 
ware answer  the  purpose  of  the  elaborate  outfit  of  a 
well-equipped  operating  theater,  Avithout  increasing  the 
risk  of  infection. 

An  ideal  surgical  nurse  talks  little,  hears  much,  and 
makes  no  unnecessary  noise.  She  is  modest,  diligent, 
courteous  and  pleasant,  but  can  be  firm  and  determined 
at  the  proper  time.  Hilarity,  if  she  has  any,  she  leaves 
at  the  threshold  of  the  sick  and  operating  room.  She  is 
dignified  on  all  occasions  and  is  never  unmindful  of  her 
position  in  life,  serving  the  sick  and  assisting  in  the 
noblest  of  all  professions. 

She  realizes  to  the  fullest  extent  the  responsibility 
Avhich  rests  on  her  when  called  upon  to  make  prepara- 
tions for  an  operation.  She  is  fully  aware  of  the  fac+ 
that  unwarranted  haste  or  the  slightest  oversight  or 
neglfgence  might  become  the  cause  of  grave  complica- 
tions, or  even  death,  although  the  operation  might  be 
performed  faultlessly  and  by  the  most  expert  surgeon. 

The  ideal  surgical  nurse  must  be  progressive.  She 
must  keep  pace  with  the  improvements  and  advances 
wliicli  are  constantly  being  made  in  her  profession, 
which  means  that  she  must  be  studious,  familiar  with 
new  text-books  and  the  current  literature  on  nursing. 
She  should  spend  most  of  her  leisure  time  in  acquiring 
more  knowledge,  rather  than  in  places  of  amusement. 

Fully  imbued  with  the  importance  and  responsibility 
of  her  vocation  in  life,  she  will  make  strenuous  efforts 
to  increase  her  usefulness  to  the  patients  mider  her 
care  and  the  surgeons  she  assists.  In  contact  with  her 
patients,  she  combines  sympathy  and  gentleness,  with 
firmness.  Her  well-poised  temper  brings  cheer  and 
hope  into  the  sick  room,  and  her  dignified  conduct  com- 
mands respect  and  submission  from  all  classes  and  sorts 
of  people — rich  and  poor,  educated  and  ignorant,  voung 
and  old. 


r  0  R      THE      OPE  RATING       ROOM.  21 

Finally,  the  ideal  nurse  is  best  known  by  her  devotion 
to  her  duties.  She  finds  her  greatest  pleasure  in  her 
work,  and  her  highest  ambition  is  success  in  her  chosen 
profession. 


Surgical  Nurse. 


Senn's    Chatelain    for    Nurses. 


CHAPTER  II. 


PREPARATION  OF  OPERATING  ROOM  IN  A  PRIVATE 
HOUSE. 

In  private  homes  a  room  is  to  be  selected  that  is  least 
frequented,  and  very  often  the  kitchen  will  recom- 
mend itself  as  the  best  for  this  purpose.  Carpets,  cur- 
tains, pictures  and  all  unnecessary  furniture  must  be 
removed.  If  time  permits,  the  disinfection  of  the 
empty  room  sliould  be  commenced  by  fumigating  with 
sulphur  dioxid  for  12  hours.  Burn  3  pounds  of  sul- 
phur for  every  1.000  cubic  feet  of  air  space  in  the  room. 
The  sulphur  must  be  burned  in  an  iron  kettle  placed  in 
a  wash  tub  partly  filled  with  water,  and  doors  and  win- 
dows should  l)e  tightly  closed  to  prevent  escape.  After 
the  expiration  of  the  12  hours,  or  if  time  does  not  ad- 
mit of  fumigation,  ceiling,  doors,  floors,  walls,  windows 
or  Ijlinds  and  all  objects  in  the  room  must  be  scrubbed 
thoroughly  with  hot  soda  solution,  to  be  followed  l)y 
scrul>bing  with  a  solution  of  corrosive  sublimate  1:1,000 
or  carbolic  acid.  5  per  cent.  The  disinfecting  sohitions 
should  invariably  be  colored  to  prevent  accidents. 

The  microbes  developed  upon  the  surface  of  the  eartli 
find  their  way  in  limited  number  into  the  lower  strata 
of  the  atmospheric  air  by  currents  of  wind  that  carry 
with  them  visible  dust.  Naegeli  showed,  a  quarter  of  a 
century  ago,  that  microbes  are  transported  through  the 
air.  through  the  mediimi  of  dry  dust,  never  from  fluid 
organic  media  in  Avhich  they  grow.  Dry  air  contains 
more  microbes  than  moist  air,  because  more  dust  is  sus- 
l^ended  in  it.  which  serves  as  a  carrier  for  the  microbes. 
Eain  carries  with  it  microbes  from  the  air  to  the  sur- 
face and  purifies  the  atmosphere. 

Xatnre's  proco'^s  should  1)('  imitated  in  the  operating 


Kitchen   Converted   Into   an   Operating    Room. 


F  0  K      THE      OPERATING      R  0  0  M.  21 

room.  The  microbes  floating  in  the  air  should  be  pre- 
cipitated by  moisture  in  the  form  of  steam  or  spray; 
by  doing  so  the  air  is  purified  and  the  microbes  become 
attached  to  the  moist  floor,  which  should  be  kept  moist 
until  the  operation  is  completed.  For  the  cleansing  of 
wall  paper  von  Esmarch  has  recommended  rubbing 
with  soft  bread,  and  his  advice  is  based  on  the  results 
of  carefully  made  experiments. 

Whenever  possible  the  room  should  be  prepared  the 
day  before  the  operation,  after  which  the  doors  and 
windows  are  closed.  In  emergency  cases  this  can  not 
be  done,  but  the  atmosphere  can  be  moistened  with 
steam  in  a  very  short  time  during  and  after  the  me- 
chanical and  chemic  cleansing  of  the  room  and  its  con- 
tents. 

The  kitchen  table  can  be  converted  into  an  operating 
table  that  will  answer  every  purpose  by  placing  upon  it 
a  blanket  properly  folded  and  covering  the  same  with  a 
5^  clean  sheet. 

The  kitchen  stove  does  excellent  service  in  sterilizing 
everything  that  can  be  sterilized  by  heat — wash  basins, 
pans,  water,  instruments,  etc.  Napkins  and  towels  that 
are  to  be  used  during  the  operation  and  the  sterility  of 
which  is  doubtful,  should  be  boiled  for  five  minutes  in 
soda  solution.  Sterile  water,  hot  and  cold,  and  saline 
solution  in  sufiicient  quantity  must  be  kept  in  readiness, 
as  well  as  sterile  vessels  for  use  during  the  operation. 

An  active,  efiicient  nurse  can  prepare  any  room  in  s 
few  hours  so  that  it  will  be  safe  to  perform  any  opera- 
tion by  making  liberal  use  of  hot  soda  solution,  hot 
water  and  potash  soap,  antiseptic  solutions  and  steam. 

For  major,  prolonged  operations  the  temperature  of 
the  room  should  be  kept  at  not  less  than  75  degrees  F. 
Warm  blankets,  bottles  filled  with  hot  water,  or  warm 
bricks  must  be  kept  in  readiness  to  supply  the  neces- 
sary heat  in  operations  on  feeble  patients,  or  in  cases 
in  which  shock  is  liable  to  set  in  as  an  immediate  effect 
of  the  operation.    A  hypodermic  s}Tinge,  strychnin  tab- 


^8  A    nurse's    guide 

lets,  capsules  of  nitrite  of  am}'!,  alcoholic  stimulants, 
ether  and  chloroform  must  be  kept  within  easy  reach 
of  the  anesthetizer. 

Brushes  used  for  hand  and  surface  disinfection  arc 
rendered  sterile  by  exposing  them  to  live  steam  for 
thirty  minutes,  or  by  boiling  them  in  soda  solution 
from  five  to  ten  minutes.  Carbonate  of  soda  dissolves 
fat  and  liberates  the  microbes  for  the  more  effective  ac- 
tion of  the  antiseptic  solution.  Ether  has  the  same  ef- 
fect and  is  used  extensively  for  the  same  purpose.  Be- 
fore hand  disinfection  is  commenced  coats  are  laid 
aside  and  the  sleeves  are  rolled  up  securely  above  the 
elbows  when  the  operator  and  his  assistants  are  ready 
for  the  operating  room.  Should  gowns  not  be  on  hand, 
night  shirts  answer  as  excellent  substitutes,  and  in  the 
absence  of  such,  a  clean  sheet  may  be  wrapped  around 
the  chest  and  abdomen  and  fastened  with  safety  pins. 
Towels  can  be  used  in  the  same  manner  for  the  arms. 

As  microbes  attach  themselves  much  more  readily  to 
woolen  fabric  than  linen  or  calico,  the  nurse  should  al- 
ways wear  a  calico  dress  and  over  it  an  aseptic  gown. 
Hair  and  beard  of  operator  and  assistants  may  be  cov- 
ered with  aseptic  gauze.  The  face  mask  of  Mikulicz  has 
found  few  imitators.  If  during  the  operation  the  hands 
of  any  one  connected  with  the  operation  should  become 
contaminated,  they  should  again  be  thoroughly  disin- 
fected. The  antiseptic  solution  which  the  operator  may 
prefer  and  the  saline  solution  should  be  placed  within 
easy  reach  to  be  used  when  his  hands  become  bloody  or 
contaminated. 


^    von   Esmarch's   Elastic    Constrictor  von  Esmareh's  Elastic 


with   Strap  and  Chain. 


Bandage. 


Autotransfusion — von  Esmarch's. 


CHAPTER  III. 


PREVENTION  AND  TREATMENT  OF  HEMORRHAGE. 

Hemorrhage  is  one  of  the  trying  emergencies  in  sur- 
gery. It  is  in  cases  where  the  surgeon  is  confronted  by 
dangerous  hemorrhage,  either  accidental  or  during  the 
course  of  an  operation,  that  he  must  act  promptly  in 
order  to  save  the  life  of  the  patient.  It  is  in  such  emerg- 
encies that  the  nurse  must  co-operate  with  him  intelli-' 
gently  to  enable  him  to  accomplish  promptly  what  ha? 
to  be  done.  The  trained  nurse  must  be  familiar  with 
the  means  employed  to  prevent  and  arrest  hemorrhage 
and  in  emergencies,  in  the  absence  of  the  surgeon, 
should  be  competent  to  act  independently  and  resort  tc 
safe  and  effective  means  to  staunch  the  bleeding  until 
the  surgeon  arrives.  Knowledge,  good  judgment  and 
self-reliance  are  essential  in  such  cases. 

Arterial  hemorrhage  is  distinguished  by  the  bright 
red  color  of  the  blood  and  by  the  jets  in  the  stream  as 
the  blood  escapes  from  the  severed  artery.  Blood  issu- 
ing from  the  veins  is  of  a  dark  color,  and  the  stream  is 
continuous. 

In  capillary  hemorrhage,  or  parenchymatous  bleed- 
ing, the  blood,  a  mixture  of  arterial  and  venous,  es- 
capes from  the  cut  surface  in  the  form  of  continuou 
oozing. 

ELASTIC  CONSTRICTION. 

The  principal  means  of  preventing  hemorrhage  from 
any  of  the  large  vessels  of  the  extremities  is  by  elastic 
constriction  as  first  intelligently  described  and  prac- 
ticed by  Professor  von  Esmarch,  a  distinguished  mili- 
tary surgeon.     The  instrument  employed  is   a  strong 


P  0  E      THE      OPERATING      E  0  0  M.  31 

rubber  band,  to  which  is  attached  on  one  side  a  chain 
and  on  the  other  a  hook. 

In  the  absence  of  the  constrictor,  a  piece  of  stont 
rubber  tubing,  an  ordinary  rubber  bandage  or  an  elastic 
suspender  may  be  advantageously  employed. 

The  limb  should  be  held  in  a  vertical  position  for  a 
few  minutes  to  render  it  practically  bloodless,  when  the 
constriction  is  made  at  its  base  with  sufficient  firmness 
to  arrest  at  once  both  the  arterial  and  venous  circula- 
tion. The  successive  turns  should  not  override  each 
other,  but  be  placed  side  by  side  in  order  to  guard 
against  harmful  pressure  on  the  underlying  large  nerve 
trunks,  which  has  occasionally  been  the  direct  cause  of 
temporary  and  even  permanent  paralysis. 

Elastic  constriction  is  also  employed  in  emergency 
cases  and  in  autotransfusion. 

It  must  be  remembered  that  it  is  dangerous  to  pro- 
long elastic  constriction  for  more  than  two  hours,  as 
*  when  it  is  continued  beyond  that  time  it  might  result 
in  gangrene  of  the  limb. 

LIGATION  OF  BLOOD  VESSELS. 

The  most  direct  and  surest  way  to  arrest  hemorrhage 
is  ligation  of  the  severed  vessel,  artery  or  vein.  This  is 
now  usually  done  by  the  use  of  the  animal  absorbable 
ligature — catgut  or  kangaroo  tendon — although  some 
surgeons  give  the  fine  aseptic  silk  ligature  the  prefer- 
ence. Sterilized  catgut  and  kangaroo  tendon  ligatures, 
according  to  their  thickness,  remain  in  the  tissues  from 
7  to  .21  days,  long  enough  to  interrupt  the  circulation 
until  the  interior  of  the  vessel  at  the  point  of  ligation 
is  obliterated,  when  they  are  removed  by  absorption  by 
the  new  tissue  cells  formed  around  them. 

Hemostatic  forceps,  artery  needle,  sharp  tenaculum 
and  a  curved  round  needle  threaded  with  catgut  are  the 
instruments  to  be  kept  in  readiness  for  the  ligation  of 
blood  vessels. 


32  A      N  U  K  S  E  ■"  S      G  U  I  D  K 

ASEPTIC  TAMPON. 

The  aseptic  tampon,  of  which  the  Mikulicz  drain  or 
tampon  is  an  example,  is  frequently  resorted  to  in  ar- 
resting capillary  hemorrhage  and  bleeding  from  vessel? 
of  small  caliber. 

HOT  SALINE  SOLUTION. 

Water  or,  better,  normal  saline  solution  heated  to  a 
temperature  of  120  degrees  F.,  is  an  important  and  eflS- 
cient  agent  in  arresting  troublesome  capillary  oozing. 
It  is  employed  by  pouring  the  hot  fluid  at  some  height 
over  the  bleeding  surface,  and  its  hemostatic  action  is 
increased  by  combining  its  use  with  compression.  A 
compress  of  sterile  gauze  is  wrung  out  lightly,  after 
dipping  it  into  the  hot  water  or  saline  solution,  when  it 
is  held  against  the  bleeding  surface  firmly  until  the 
bleeding  ceases. 

INDIRECT  LIGATURE. 

In  troublesome  bleeding  from  vessels  of  considerable 
caliber  not  within  reach  of  a  direct  ligature,  a  round, 
curved  needle  armed  with  catgut  is  used,  and  the  liga- 
ture is  made  to  include  some  of  the  surrounding  tissue 
to  prevent  slipping;  in  other  words,  the  indirect  liga- 
ture is  resorted  to  in  cases  in  which,  either  on  account 
of  friability  of  the  vessel  or  the  nature  of  the  surround- 
ing, the  direct  ligature  has  proved  inapplicable. 

In  suturing  wounds  of  arteries  or  veins,  the  finest  silk 
ligature  and  delicate,  curved,  round  needles  are  invari- 
ably called  for  and  must  be  kept  in  readiness. 


CHAPTER  XIV. 


THE  USES  OF  NORMAL  SALT  SOLUTION  IN  SURGERY. 

Within  a  few  years  the  normal  salt  solution,  or,  as  it 
is  often  called,  physiologic  solution,  has  almost  entirely 
taken  the  place  of  sterilized,  water  in  the  operating 
room.  In  my  own  practice  the  latter  has  been  entirely 
eliminated. 

The  effect  of  this  solution  on  wounds  is  less  harmful 
than  that  of  water,  as  it  represents,  chemically,  blood 
serum  and  the  tissue  fluids. 

Thef  solution  is  prepared  by  dissolving  in  sterilized 
water  six-tenths  of  one  per  cent,  of  chemically  pure  salt. 
^For  the  irrigation  of  recent  wounds  it  is  the  very  best 
that  can  be  employed,  and  if  it  is  used  hot,  is  a  valu- 
able agent  in  arresting  capillary  oozing. 

It  is  also  in  very  general  use  in  flushing  the  abdomi- 
nal cavity  for  the  removal  of  blood  and  pus.  Its  present 
most  important  use  in  surgery  consists  in  meeting  the 
urgent  symptoms  in  the  treatment  of  grave  shock  and 
serious  hemorrhage. 

Its  therapeutic  action  is  largely  a  mpchanieal  one,  by 
increasing  the  failing  blood  pressure.  According  to  the 
urgency  of  the  case,  it  is  administered  in  three  different 
ways:  (1)  intravenous  infusion,  (3)  subcutaneous  in- 
jection, (3)  rectal  enemata, 

INTRAVENOUS  INFUSION. 

This  procedure  has  almost  entirely  taken  the  place 
of  transfusion  of  living  blood  from  one  person  to  an- 
■  other,  or  from  an  animal  to  a  person. 

This  operation  is  resorted  to  in  cases  of  grave  shock 
or  dangerous  hemorrhage;  cases  in  which  it  is  necessary 
to  gain  its  therapeutic  action  promptly. 


34.  A    nurse's    guide 

Aseptic  measures  must  be  strictly  observed  in  this  as 
in  all  otber  operations;  this  is  especially  to  be  remem- 
bered, as  this  operation  has  usually  to  be  performed  in 
haste  to  meet  alarming,  dangerous  sjTnptoms.  Articles 
needed : 

One  elastic  constrictor. 

One  small  scalpel. 

One  tenotome. 

Two  tissue  forceps. 


Intravenous    Saline    Infusion.      Manner    of    Incising    Vein    and 
Inserting  Glass  Tube. 

Two  tenaculum  hooks. 

Two  blunt  hooks. 

Two  pairs  scissors. 

Three  artery  forceps. 

One  aneurysm  needle. 

One  pair  small  retractors. 

One  small  canula  (a  glass  tube  drawn  out  into  a  fine 
point),  to  which  is  attached  a  small  rubber  tube  sixteen 
inches  long.  At  the  other  end  of  the  tubing  attach  a 
glass  cylinder  or  fimnel  (a  glass  syringe  without  a  pis- 
ton will  answer).     Into  the  receptacle  is  ponred  the 


rOR      THE      OPERATING      ROOM.  35 

phj'siologic  solTition  at  a  temperature  of  100  degrees  F. 
Prepare  one  quart  of  this  solution  in  di&tiJled  or  steril- 
ized water. 

In  emergency  cases  the  ordinary  fountain  syringe  i? 
sometimes  used. 

Ligatures  : 

Aneurysm  needle   armed  with  medium-sized   catgut 
or  fine  silk  ten  inches  long  to  ligate  vein. 

Sutures : 

Two  glover's  needles  for  silkworm  gut  or  silk. 

One  glover's  needle  for  horsehair. 
Dressing  : 

Boro-salicylic  powder^  4:1. 

Sterilized  gauze  and  cotton. 

Three  sterilized  towels. 

Sterilized  gauze  sponges. 

EoUer  bandage  and  safety  pins. 

There  is  one  great  danger  attending  this  operation — 
the  injection  of  air  into  the  vein  causing  air-embolism. 
To  avoid  this,  see  that  the  solution  is  running  freely 
before  the  surgeon  inserts  the  canula. 

SUBCUTANEOUS  INJECTION. 

In  less  urgent  cases  the  same  object  is  reached  in  a 
longer  time  by  injecting  the  solution  into  the  loose  sub- 
cutaneous cellular  tissue  under  the  breast,  below  the 
axillary  space,  or  in  some  other  locality  where  the  skin 
can  be  easily  lifted  away  from  the  underlying  muscles. 

As  much  as  a  quart  of  the  solution  at  blood  tempera- 
ture can  be  safely  injected  at  one  time. 

A  large  exploring  needle  or  a  small  trocar  is  used  in 
making  the  puncture,  to  which  is  then  attached  the  rub- 
ber tube  at  least  six  feet  in  length,  which  connects  it 
with  the  vessel  containing  the  solution  (usuallv  a  large 
conical  glass  vessel  with  a  contracted  tip  at  the  conical 
end,  or  an  ordinary  rubber  irrigation  bag). 

The  fluid  is  forced  gentlv  into  the  connective  tissue 


36  A    nurse's    guide 

by  elevating  the  vessel  four  to  six  feet  above  the  level  of 
the  point  of  puncture. 

EJQeading  the  seat  of  injection  aids  in  diffusing  the 
fluid  underneath  the  skin. 

The  point  of  puncture  must  be  carefully  disinfected, 
and  needle  or  trocar,  vessel  and  solution,  sterilized  by 
boiling. 

RECTAL     ENEMA. 

The  rectal  mucous  membrane  absorbs  the  saline  solu- 
tion very  rapidly;  hence,  if  time  does  not  have  to  be 
considered,  this  is  the  route  usually  selected  to  supply 
the  blood  with  the  necessary  amount  of  fluid.  A  quart 
can  be  administered  in  this  manner  without  inconveni- 
encing the  patient. 

In  giving  the  injection  the  patient  should  be  placed 
on  the  right  side  with  pelvis  elevated,  and  the  fluid 
should  flow  somewhat  slowly  from  the  fountain  syringe. 

Eectal  enemata  are  frequently  given  the  day  before 
abdominal  section  to  prevent  distressing  thirst  follow- 
ing the  operation. 


Subcutaneous    SaliHe   Infusion. 


CHAPTER  V. 


URINALYSIS. 

The  kidiie5's  are  excretory  organs,  which  carry  away 
much  of  the  waste  material  of  the  body  through  the 
urine.  Serious  textural  diseases  of  these  organs  are  made 
manifest  by  alterations  in  the  urine  which  on  chemical 
or  microscopic  examination,  shows  the  presence  of  ab- 
normal pathogenic  products,  such  as  blood,  pus,  con- 
cretions, casts,  epithelial  cells  and  albumin. 

For  the  purpose  of  ascertaining  the  existence  of  renal 
complications  during  the  course  of  many  acute  and 
chronic  diseases,  the  urine  is  frequently  subjected  to  a 
careful  examination.  The  urine  is  invariably  examined 
^  before  the  administration  of  a  general  anesthetic,  as  the 
existence  of  renal  disease  indicated  by  such  examination 
has  mucli  influence  in  the  selection  of  the  anesthetic. 
Many  surgeons  hesitate  to  make  use  of  sulphuric  ether 
'  as  an  anesthetic  for  patients  affected  with  organic  dis- 
ease of  the  kidneys.  Of  all  acute  infectious  diseases 
scarlatina  is  the  one  in  which  the  kidneys  become  most 
frequently  implicated.  Hence  in  such  cases  the  nurse 
is  expected  to  pay  special  attention  to  the  function  of 
these  organs,  and  make  repeated  examination  of  the 
urine,  especially  during  the  latter  stages  of  the  disease 
and  the  first  week  of  convalescence. 

Every  trained  nurse  must  be  competent  to  make  the 
ordinary  urine  tests  to  determine  the  presence  or  ab- 
sence of  the  most  common  forms  of  renal  disease,  as 
this  part  of  the  examination  is  not  infrequently  as- 
signed to  her  by  the  attending  physician  or  surgeon. 
She  is  not  expected,  however,  to  be  an  expert  in  the  use 
of  the  microscope,  or  familiar  with  the  finer  and  more 
complicated  chemical  tests. 


40  A    nurse's    guide 


NORMAL     URINE. 


i!^ormal  urine  is  a  straw  colored  fluid,  almost  colorless 
when  abundant.  In  the  adult  the  daity  quantity  varies 
from  thirty-two  to  fifty  ounces';  :  It)  has  a  distinct  acid 
reaction,  turning  blue  litmus  paper  red,  the  intensity 
of  the  red  coloration  furnishing  an  approximate  indi- 
cation of  the  degree  of  acidity.  On  exposure  to  the  at- 
mospheric air  it  soon  becomes  neutral  or  alkaline  by 
decomposition  of  urea  and  formation  of  ammonium 
carbonate. 

Alkaline  urine  does  not  change  the  color  of  blue  lit- 
mus paper,  but  turns  the  red  litmus  paper  blue.  It 
must  be  remembered  that  the  color  and  reaction  of 
urine  are  influenced  by  some  drugs.  Ehubarb  and  senna, 
favorite  laxatives,  cause  a  reddish  yellow  to  deep  red 
color,  especially  in  alkaline  urine.  Santonin  produces  a 
bright  yellow  color,  changing  to  red  or  crimson  on  the 
addition  of  an  alkili.  The  internal  use  of  carbolic  acid 
or  the  absorption  of  this  drug  when  externally  applied 
causes  a  smoky,  or  even  black,  discoloration  of  urine, 
while  large  doses  of  salicylic  acid  color  it  green. 

The  admixture  of  bile  in  cases  of  jaundice  gives  to 
the  urine  the  familiar  light  or  dark  beer  color,  accord- 
ing to  the  intensity  of  the  jaundice.  The  odor  of  fresh 
urine  is  characteristic ;  of  decomposed  alkaline  urine, 
ammoniacal. 

The  specific  gTavity  of  normal  urine  varies  consider- 
ably, according  to  its  density.  The  average  from  1.012 
to  1.033.  A  specific  gravity  above  1.030  may  give  rise 
to  the  suspicion  of  the  presence  of  sugar;  larger  quan- 
tities of  which  may  cause  this  specific  gravity  to  arise  to 
1.050,  and  even  higher  in  established  and  far-advanced 
cases  of  diabetes. 

It  must  not  be  forgotten  that  the  specific  gravity  of 
urine  considered  separately  from  the  quantity  passed  in 
twenty-four  hours  is  of  little  diagnostic  value,  and  that 
in  some  diseases  (for  instance,  in  acute  nephritis  with 
albuminuria)   the  specific  gravity  of  albuminous  urine 


P  0  K      THE      0  r  E  ]l  A  T  I  X  G      ROOM 


41 


may  be  as  high  as  1.030,  while  a  diabetic  urine  may 
have  a  specific  gravity  of  1.025  or  less,  in  consequence  of 
a  large  volume  passed. 

The  specific  gravity  of  urine  is  determined  by  the  use 
of  a  urinometer,  which  is  a  small  hydrometer  graded 
from  zero  or  1000  to  60  or  1060. 

As  the  temperature  infiuences  liquids  as  to  their 
density,  a  urinometer  can  only  give  correct  results  at  a 
certain  temperature,  which  is  generally  marked  upoii 
the  instrument.  60  degrees  F. 


5* 


Ordinary  Urinometer. 


In  taking  the  specific  gravity  of  urine,  the  quantity 
must  be  sufficient  to  float  the  instrument,  and  the  vessel 
in  which  it  is  contained,  wide  enough  so  that  it  will  not 
impinge  upon  its  walls.  After  the  instrument  is  in 
proper  position  and  floating  freely,  stand  with  the  back 
to  the  light,  hold  the  vessel  vertically  at  the  height  of 
the  eye,  and  read  off  the  number  on  the  stem  of  the 
urinometer,  in  the  plane  at  the  lower  sharply  defined 
edge  of  the  concave  surface  of  the  liquid. 


42  A    nukse's    guide 

BLOOD     AND     PUS. 

Blood  and  pus  are  heavier  than  urine.  Hence,  if 
iirine  is  left  to  stand  for  some  time,  they  will  settle  to 
the  bottom  of  the  vessel.  These  abnormal  substances 
in  the  urine,  when  present  in  considerable  amount,  can 
be  detected  and  the  quantity  approximateh'  estimated 
by  pouring  the  urine  into  a  conical  glass  and  allowing 
it  to  stand  for  some  time.  Avhen  the  color  of  the  deposit 
will  show  its  nature  and  quantity. 

TEST     FOR     ALBUMIN. 

The  rough,  and  yet  quite  reliable  tests  to  detect 
albumin  in  urine  are  heat  and  nitric  acid.  In  a  test  tube 
about  an  ounce  of  urine  is  heated  slowly  to  the  boiling 
point,  and  if  by  so  doing  the  urine  is  rendered  turbid 
a  drop  or  two  of  acetic  or  nitric  acid  are  added.  If  the 
turbidity  is  caused  by  the  presence  of  albumin  it  will 
remain:  if  it  is  the  result  of  an  abnormal  presence  of 
inorganic  salts  it  will  disappear.  In  using  the  nitric 
acid  alone,  proceed  as  follows :  Take  a  clean  test  tube ; 
pour  into  it  pure,  colorless  nitric  acid  to  the  depth  of 
about  half  an  inch;  hold  it  on  an  inclination  of  about 
45  degrees;  then,  with  a  nipple  pipette,  add  an  equal 
amount  of  urine,  allowing  it  to  trickle  slowly  down 
the  side  of  the  test  tube  in  such  a  manner  that  the  urine 
forms  a  distinct  and  separate  layer  over  the  nitric  acid. 
If  albumin  is  present  a  white  zone  of  varying  thickness 
(according  to  the  quantity  of  albumin  present)  appears 
at  the  point  of  contact  of  the  fluids. 

In  country  practice,  if  there  are  no  conveniences  at 
hand  for  testing  the  urine,  the  presence  of  albumin 
can  be  determined  by  bringing  the  urine  to  a  boiling 
point  in  a  tablespoon  held  over  a  coal  or  a  wood  fire  and 
when  a  deposit  forms,  add  a  few  drops  of  vinegar.  If 
the  deposit  remains,  the  urine  is  albuminous. 

TEST    FOR     SUGAR. 

Fehling's  or  Haine's  test  may  be  employed,  as  both 
of  them  are  reliable,  if  sugar  is  present  in  any  consid- 


FOR      THE      OPERATING      ROOM.  43 

erable  quantity.  In  this  country  Haine's  solution  is, 
perhaps,  more  commonly  employed.  If  the  suspected 
urine  contains  albumin,  it  should  first  be  removed  by 
boiling  and  filtration,  as  its  presence  interferes  with  the 
reduction  of  copper.  Pour  into  a  clean  test  tul>e  about 
one  inch  of  the  solution  and  heat  slowly  over  the  flame 
of  a  spirit  lamp.  Before  boiling  hold  the  tube  in  an 
inclined  position  at  an  angle  of  45  degrees.  Hold 
only  the  side  of  the  tube  to  the  flame  and  heat  from 
above,  downward,  to  prevent  explosive  boiling  and  loss 
of  solution.  If  any  precipitate  is  formed,  the  solution 
must  be  filtered  and  boiled  again.  If  it  remains  clear 
add  immediately  5  to  10  drops  (not  more),  drop  by 
drop,  of  the  urine  to  be  tested,  and  reboil.  If  sugar  is 
present  it  is  shown  by  the  rapid  production  of  a  brick 
red  or  rich  yellow  precipitate  of  suboxid  of  copper, 
which  will  soon  settle  to  the  bottom. 

,  USE     AND     CARE     OF     CATHETERS. 

The  catheter  is  a  tubular  instrument  made  of  silver, 
glass  or  flexible  rubber,  used  for  the  purpose  of  empty- 
ing the  bladder  when,  owing  to  abnormal  conditions 
of  the  bladder  or  its  outlet,  normal  micturition  is  im- 
peded. The  catheters  for  females  are  straight,  with  a 
short  curved  beak.  Kelly's  glass  catheter  is  an  excel- 
lent instrument,  and  should  be  used  in  preference. 

A  catheter  that  is  not  surgically  clean,  that  is  asep- 
tic, is  always  a  dangerous  instrument;  hence  the  neces- 
sity of  sterilizing  it  before  using,  and  keeping  it  in 
an  aseptic  condition,  when  it  has  to  be  used  repeatedly. 
Boiling  in  a  1  per  cent,  solution  carbonate  of  soda  for 
five  minutes  suffices  to  render  it  aseptic.  The  hands 
of  the  one  who  uses  it,  as  well  as  the  meatus  or  outlet 
of  the  urethra,  must  be  disinfected  before  each  inser- 
tion in  order  to  prevent  subsequent  contamination  of  the 
instrument,  and  the  transportation  of  pathogenic  mi- 
crobes from  the  infected  orifice  into  the  bladder.     This 


iMM^ja^trTmy-' '  •■'  ■  -""^  -  -"->"^-'" 


Female  Catheter,  Glass. 


Flexible   Paibber   Catheter. 


i~ui 


Kelly's  Double?  Catheter,    Gl.nss,   for   Irrigation  of  the   Bladder. 


^f  ■  ,  -  %»-. 

f» 

r 

F 

■ 

■  ■ 

■ 

i 

1 

i 

1 

1 

i 

1   i 

1 

"CiH 

» 

■"  1 

Glass  Jar  for  Catheters. 


FOE      THE      OPERATING       E  0  0:M  .45 

can  be  done  with  one  of  the  antiseptic  solutions  or  di- 
luted alcohol. 

The  instrument  must  be  lubricated  with  some  asep- 
tic fatty  material  to  facilitate  its  insertion.  Fatty  ma- 
terial as  a  coating  for  the  instrument  is  of  value  not 
only  in  a  mechanical  way,  but  also  in  furnishing  for 
the  urethral  microbes  a  mantel  of  an  indiiferent  sub- 
stance, and  in  so  doing  prevents  their  contact  with  the 
mucous  membrane  of  the  bladder.  The  best  prepara- 
tion to  fulfill  these  indications  for  aseptic  catheteriza- 
tion is  sterilized  white  vaselin  with  the  addition  of 
2%  per  cent,  carbolic  acid,  or  one-tenth  of  1  per  cent, 
formic  aldehyd.  This  ointment  should  be  kept  in  col- 
lapsible tubes,  and  carried  in  every  emergency  bag. 

After  use,  the  catheters  should  be  thoroughly  cleansed, 
and  suspended  in  a  high  glass  jar  with  a  wide  mouth 
and  closely  fitting  glass  stopper. 

It  was  formerly  customary  to  keep  the  catheter  in 
"^  an  antiseptic  solution,  but  this  caused  the  rubber  soon 
to  become  rough  and  fragile.  It  may  be  kept  aseptic 
by  placing  in  the  bottom  of  a  glass  jar  a  few  tablets 
of  formalin.  The  gaseous  product  from  the  tablets 
fills  the  jar  and  keeps  the  instrument  in  a  sterile  con- 
dition. 

The  nurse  who  has  in  charge  a  patient  who  has  en- 
tered upon  a  catheter  life,  should  supply  herself  with 
a  number  of  catheters,  and  suspend  them,  after  ster- 
ilization, in  the  formalin  jar.  Before  using,  the  instru- 
ment should  be  thoroughly  rinsed  in  warm,  sterilized 
water. 


CHAPTER  VI. 


CLINICAL  THERMOMETRY. 

The  art  of  reading  thermometers  and  taking  tem- 
perature is  among  the  first  instructions  which  young 
nurses  (beginners)  receive,  and  they,  as  well  as  those 
experienced  in  the  work  of  nursing,  should  give  the  tak- 
ing of  temperature  their  conscientious  attention. 

They  should  not  leave  the  patient  while  taking  the 
temperature,  as  he  might  remove  the  thermometer  and 
thus  cause  the  evidence  to  be  incorrect.  The  treatment 
of  the  case  may  depend  largely  upon  the  record  which 
the  nurse  makes  of  the  temperature,  and  attention  to 
detail  in  this  characterizes  the  earnest  nurse. 

A  thermometer  is  an  instrument  used  to  measure 
temperature.  In  the  manufacture  of  clinical  and  scien- 
tific thermometers,  mercury  is  invariably  employed  as 
the  expanding  agent. 

In  1G93  Fahrenheit  first  used  mercury  in  this  capac- 
ity in  thermometers,  making  the  freezing  point  32  de- 
grees and  the  boiling  point  212  degrees  above  zero.  Al- 
though this  scale  proved  inconvenient  for  scientific  pur- 
poses, it  is  at  the  present  time  more  largely  used  in  this 
country  and  Great  Britain  than  any  other. 

Eeanmur,  about  forty  years  later,  presented  the  metric 
scale,  marking  zero  as  the  freezing  point  and  the  boiling 
point  80  degrees  above  it.  Some  European  countries 
still  employ  this  system. 

Celsius,  in  1742,  produced  a  better  instrument  by 
raising  the  boiling  point  20  degi-ees  in  his  scale  and 
marking  it  as  100  degrees  above  the  freezing  point  or 
zero.  This  latter  is  known  as  the  centigrade  or  Celsius 
scale.  In  Germany  the  centigrade  thermometer  is  used 
almost  exclusively,  and,  as  physicians  educated  in  Ger- 
many are  partial  to  this  instrument,  it  is  quite  neces- 


F. 


> 


-2X2. 

'111- 

-[S2. 
-132 

-  ^2- 

-  S2. 
-32 


i 


100 

so 

ho 

4-0 
.  0-0 
.  0 


i 


60 
^0 

■  :lo 

■  0 


i 


Clinical    Thermometers. 


48  A    N  u  R  s  i: '  s     o  u  I  D  ]■ 

sary  that  nurses  should  be  able  to  convert  one  scale  into 
another,  and  for  the  convenience  of  those  who  are  not 
familiar  with  the  process  the  following  table  is  ap- 
pended, also  a  cut  of  the  thermometers  described  in 
the  foregoing. 

To  convert  centigrade  into  Fahrenheit  multiplv  by 
9,  divide  by  5,  and  add  32  to  the  result. 

EXAjrPLE. 

Boiling  Point.  Boiling  Point. 

Centigrade.  Fahrenheit. 

100°X0=:900°H-.5=il80M--'52°=212°. 

Or  to  reverse  the  process : 

Boiling  Point.  Boiling  Point. 

Fahrenheit.  Centigrade. 

212°— 32°=180°X5=900°^9=100°. 

To  convert  Fahrenheit  to  Eeauumr  proceed  as  before. 

but  use  4  as  a  divisor  instead  of  5. 

EXAMPLE. 

Boiling  point.  Boiling  point. 

Egaumur.  Fahrenheit. 

80=xn=72(r-f-4=lS0°+.'32°=212°. 

The  thermometer  should  always  be  kept  surgically 
clean.  The  instrument  can  not  be  sterilized  by  boiling. 
After  using,  it  should  be  thoroughly  cleansed  and  care- 
fully wiped  with  a  gauze  sponge  saturated  with  pure 
alcohol.  The  temperature  is  taken  in  three  different 
ways:  First,  the  mouth;  second,  the  axilla;  third,  in 
the  rectum.  The  axillary  temperature  is  generally  about 
one  degree  lower  than  the  temperature  in  the  mouth 
and  rectum.  If  the  thermometer  is  used  in  the  mouth 
it  should  be  placed  imder  the  tongue  and  the  patient 
requested  to  close  the  lips  gently  over  the  projecting 
part  of  the  instrument  and  to  keep  them  fixed  in  that 
position  the  necessary  length  of  time,  which  is  on  an 
average  of  about  five  minutes. 

In  taking  the  axillary  temperature  the  instrument 
is  placed  in  the  upper  part  of  the  axillary  space  and  the 
arm  placed  closely  against  the  chest  wall.  A  longer 
time  is  required  to  take  the  temperature  in  the  axilla 


FOR     THE      OPERATING      ROOM  49 

than  in  the  mouth  or  rectum.  In  young  children,  un- 
conscious, delirious  or  insane  patients,  the  thermometer 
must  never  be  placed  in  the  mouth.  The  thermometer 
is  alwaj^s  resorted  to  after  operations,  as  its  indications 
are  of  the  greatest  importance  in  determining  the  con- 
dition of  the  patient.  A  subnormal  temperature  arouses 
suspicion  of  shock  or  hemorrhage.  A  sudden  rise  of  tem- 
perature within  twelve  hours  suggests  fermentation 
fever  caused  by  the  absorption  of  fibrin  ferment  formed 
by  the  blood  which  has  accumulated  in  the  wound. 
A  normal  temperature  for  a  day  or  two,  followed  by  a 
gTadual  rise  in  temperature,  is  only  too  often  the  fore- 
runner of  sepsis,  the  result  of  infection  of  the  wound. 
In  inflammatory  surgical  complications  and  the  con- 
tinued fevers  the  •danger  of  life  as  indicated  by  the 
thermometer  is  much  greater  when  the  temperature  re- 
mains continually  3  to  5  degrees  F.  above  the  normal 
than  when  the  curves  are  sharp,  although  the  maximum 
temperature  may  be  much  higher  at  certain  times,  usual- 
ly in  the  evening  or  during  the  night.  In  acute  inflam- 
matory affections  recovery  is  often  announced  by  a  sud- 
den fall  of  the  temperature.  In  other  instances  the  de- 
cline is  gradual.  A  temperature  of  106  or  108  degrees 
F.  is  a  signal  of  great  danger. 


CHAPTER   VII. 


METRIC     DATA. 

Nurses  are  not  always  familiar  with  quantities  ex- 
pressed in  the  metric  system,  hence  are  inserted  simple 
data  which  may  be  of  use. 

The  meter,  a  Greek  word  meaning  measure,  is  the  unit 
of  length;  it  approaches  very  nearly  to  our  common 
yard.  This  measure,  or  meter,  is  divided  into  fractional 
lengths  of  tenths,  hundredths  and  thousandths, 

The  tenth  of  a  meter  is  called  the  decimeter,  the  pre- 
fix deci  meaning  1-10.  The  hundredth  of  a  meter  is 
called  the  centimeter,  the  prefix  centi  meaning  1-100. 
The  thousandth  of  a  meter  is  called  the  millimeter,  the 
prefix  milli  meaning  1-1.000. 

If  one-tenth  of  a  meter  i=;  one  decimeter,  then  ten 
decimeter?  must  make  one  meter. 

One  one-hundredth  of  a  meter  being  one  centimeter, 
then  one-hundred  centimeters  must  make  one  meter. 

One  one-thousandth  of  a  meter  being  one  millimeter, 
then  one  thousand  millimeters  must  make  one  meter. 

The  terms  of  expressing  the  multiples  of  the  meter 
are:  Ten  meters  make  one  decameter,  the  prefix  deca 
meaning  tenfold. 

One  hundred  meters  make  one  hectometer,  the  prefix 
hecto  meaning  100-fold.  One  thousand  meters  make 
one  kilometer,  the  prefix  kilo  meaning  1,000-fold. 

Ten  thousand  meters  make  one  myriameter,  the  pre- 
fix myria  meaning  10.000-fold. 

The  following  diagram  shows  the  relation  between 
the  metric  and  the  linear  measure: 

It  is  seen  that  the  measurements  both  of  the  multi- 
ples and  subdivisions  increase  and  decrease  by  tens. 
From  the  measure  of  lengths  all  others  are  obtained, 
those  of  capacity,  weight  and  area.    The  unit  of  a  fluid 


Fia.  1. 


h 


'•Jc'cTT'^X 


XCan. 


Metric    Diagram.       (Remington. 


Length. — Meter.  One  side  of  tlie  above  square  measures  1  deci- 
meter;  it  i.s  graduated  into  tenths  (centimeters),  and  these  into 
ten,tliB  (millimeters)  :  10  decimeters  equals  1  meter,  equals 
39.370432    inches. 

Capacity. — ^Liter.  A  hollow  cube  having  each  side  of  the  same 
size  as  the  square  would  hold  a  liter  equals  1000  c.c.  equals 
2,113433    pints. 

Weight.— Gram.  The  weight  of  distilled  water  at  4  C.  (39.2  F.) 
contained;  in  a  cube  of  the  size  of  X  (/lOOO  of  a  liter)  is  equal 
to  a  gram  equals  15.43234874  grains,  and  measures  1  cubic  centi- 
meter. 


52  axukse'sguide 

measure  is  cleriA-ecl  in  this  way :  A  cube  is  constructed  of 
1/10  of  a  meter,  or  one  decimeter,  in  all  its  dimensions 
of  length,  breadth  and  depth.  This  vessel  is  the  unit  of 
capacity  and  is  called  a  liter.  This  unit  is  too  large — 
being  the  equivalent  to  about  one  quart — for  use  in 
measuring  medicines,  and  just  as  we  find  no  use  for 
gallons,  quarts  and  pints,  but  use  fluid  ounces,  fluid 
drams  and  minims,  so  with  the  metric  S5^stem,  we  throw 
aside  the  liter  and  use  one  of  its  subdivisions.  In  place 
of  a  cube  one  decimeter  in  all  its  dimensions  we  con- 
struct one  that  is  one  centimeter,  or  1/100  of  a  meter 
in  length,  breadth  and  depth,  and  we  call  this  vessel  a 
cubic  centimeter,  using  the  abbreviated  sign  c.c.  The 
unit  of  weight  is  called  a  gram  and  is  expressed  by  gm. 
The  weight  which  will  exactly  balance  a  cubic  centime- 
ter vessel  filled  with  water  gives  us  this  unit  called  the 
gram.  We  have,  then,  for  our  units  the  meter,  or  meas- 
ure of  length;  the  cubic  centimeter,  or  measure  of  fluid 
quantities;  the  gram,  or  measure  of  weight. 

THE   FRENCH   OR  METRIC   SYSTEM   OF   WEIGHTS   AND 
MEASURES. 

A    SHORT    TABLE    OF    EQUIVALENTS    EASY    TO    REMEMBER. 

500  c.c  in  place  of  one  pint. 
500  gm.  in  place  of  one  pound  avoirdupois. 
30  c.c  in  place  of  one  fluid  ounce. 
30  gm.  in  place  of  one  ounce  weight. 
4  c.c.  in  place  of  one  fluid  dram. 
4  gm.  in  place  of  one  dram  weight. 
1  c.c.  in  place  of  m.  15. 
1  gm.  in  place  of  grs.  15. 

Reversing  Them: 

One  pint  in  place  of  500  c.c. 
One  pound  in  place  of  500  gm. 
One  fluid  ounce  in  place  of  30  c.c. 
One  ounce  weight  in  place  of  30  gm. 
One  fluid  dram  in  place  of  4  c.c. 
One  dram  weight  in  place  of  4  gm. 


F  0  R    T  H  E    0  P  E  R  A  T  I  X  G      ROOM  53 

Fifteen  minims  in  place  of  1  c.c. 

Fifteen  grains  in  place  of  1  gm. 

One  teaspoonful,  or  fluid  dram,  in  place  of  4  c.c. 

One  dessertspoonful,  or  2  drams,  in  place  of  8  c.c. 

One  tablespoonful,  or  4  drams,  in  place  of  16  c.c. 

One  wineglassful,  or  2  fl.  ounces,  in  place  of  60  c.c. 

One  cupful,  or  4  fl.  ounces,  in  place  of  120  c.c. 

One  tumblerful,  or  8  fl.  ounces,  in  place  of  240  c.c. 

The  equivalents  for  fractional  parts  of  a  grain  are 

quite  easy  to  obtain  mentally  if  the  equivalent  of  one 

grain  is  memorized.     This  equivalent  is  65  milligrams. 

and  is  written  thus :  0.065  gm.,  or  65/1,000  of  a  gram. 

Sixty-five  milligrams  being  one  grain,  then  the  half  of 

a  grain  would  be  half  of  65  milligrams,  which,  in  round 

numbers,  would  be  0.033  gm.   (33  milligrams). 

1/3  grain  would  be  1/3  of  0.065  or  0.020  gm. 
1/4  grain  would  be  1/4  of  0.065  or  0.016  gm. 
1/8  grain  would  be  1/8  of  0.065  or  0.008  gm. 
1/10  grain  would  be  1/10  of  0.065  or  0.006  gm. 
1/30  grain  would  be  1/30  of  0.065  or  0.002  gm. 
1/60  grain  would  be  1/60  of  0.065  or  0.001  gm. 

ANTISEPTIC  SOLUTIONS   IN  MOST  COMMON  USE. 

Bichlorid  of  Mercury  Solution. — The  standard  solu- 
tion is  1 :1,000,  Avhich  should  be  colored  Avith  anilin 
blue  and  properly  labeled.  This  is  the  solution  most 
generally  used  at  the  present  time  for  hand  and  sur- 
face disinfection.  Like  carbolic  acid,  it  is  never  used 
in  the  disinfection  of  the  mucous  cavities  or  passages. 
For  the  irrigation  of  suppurating  wounds  and  local  ap- 
plication by  hot,  moist  compresses  the  strong  solution 
is  diluted  from  two  to  five  times  for  the  purpose  of  di- 
minishing the  risk  of  intoxication,  and,  as  is  well 
known,  a  solution  of  1 :100,000  exerts  an  inhibitory  ac- 
tion on  pathogenic  microbes. 

STANDARD   BICHLORID    OF  MERCURY  SOLUTION. 

Hydrai"g.    bichlorid    cor QIV2  grs 

Citric  acid  or  sodium  chlorid 61 14  grs 

Water    1  gal 


54  anuese'sguide 

To  make  1 :2000.  take  one  pint  of  1 :1000  and  a  pint 
of  boiled  water. 

To  make  1:3000,  take  one  pint  of  1:1000  and  two 
pints  of  boiled  water. 

To  make  1 :4000,  take  one  pint  of  1 :1000  and  three 
pint=  of  boiled  water. 

Continue  the  same  scale  for  weaker  solutions. 

CARBOLIC     ACID     SOLUTION. 

Five  per  cent,  is  the  standard  solution.  It  should  be 
colored  with  eosin  to  prevent  mistakes.  For  hand  dis- 
infection the  strong  solution,  5  per  cent.,  is  used.  For 
the  disinfection  of  large  accidental  wounds  and  in  pre- 
paring an  extensive  field  of  operation,  a  214  per  cent. 
will  suffice.  The  2i/>  per  cent,  solution,  made  by  mix- 
ing equal  parts  of  the  5  per  cent,  solution  and  sterilized 
water,  is  the  one  usually  employed  for  washing  out 
suppurating  joints  after  tapping,  parenchymatous  in- 
jections, hot,  moist  antiseptic  dressings,  and  irrigation 
of  suppurating  wounds.  Carbolic  acid  in  any  form 
should  not  be  used  in  infants  and  young  children,  and 
must  be  used  with  great  caution  in  aged,  anemic,  maras- 
mic  subjects  and  patients  suffering  from  organic  disease 
of  the  kidneys. 

CARBOLIC  ACID  SOLUTION. 

Five  per  cent,  solution  take  95  per  cent,  carbolic  acid.  .614  oz. 
Sterilized   water    1  gal 

BORIC     ACID     SOLUTION. 

Boric  acid  is  a  mild  antiseptic,  and  in  solution  is 
used  for  indications  similar  to  those  in  which  Thiersch's 
solution  is  employed. 

Four  per  cent,  constitutes  a  saturated  solution.  Very 
few  cases  of  intoxication  have  been  reported  from  its 
use. 

BORIC  ACID  SOLUTIOX. 

Boric  acid  4  per  cent o  oz..  1  dr 

Boiled  water   1  gal 


FOE     THE      0  P  E  R  A  T  I  X  G      E  0  0  :*!  OO 

The  moist  boric  compress  is  an  admirable  substitute 
for  the  old-fashioned,  filthy,  germ-breeding  poultices. 

SALICYLIC    ACID    SOLUTION. 

Salicylic  acid  is  one  of  the  safest  and  most  valuable 
of  all  antiseptics  known.  Its  introduction  into  surgerj^ 
we  owe  to  Thiersch.  It  has  been  used  very  extensively 
in  the  preparation  of  dressing  materials,  as  it  has  been 
incorporated  with  nearly  every  substance  employed  as 
an  absorbent  covering  for  wounds.  It  is  only  slighth- 
soluble  in  Avater,  hence  it  has  been  used  in  the  form  of 
an  emulsion  (1:5)  when  a  stronger  preparation  than 
a  saturated  solution  was  required.  A  10  per  cent,  oint- 
ment with  vaselin,  lanolin  or  glycerin  is  one  of  the  best 
applications  for  the  toxic  dermatitis  caused  by  corrosive 
sublimate  and  iodoform. 

SALICYLIC    ACID     SOLUTIO^T     3:1000. 

Salicylic    acid    184  grs 

Soda  bicarb    120  grs 

Mix  Avell  and  gradually  add  boiled  water  to  make  one  gal- 
lon. 

THIERSCH'S    SOLUTION. 

A  combination  of  salic3date  and  boric  acid  makes  a 
very  efficient  and  safe  antiseptic,  either  in  the  form  of 
powder  or  solution.  Boric  acid  increases  the  antiseptic 
properties  of  salicylic  acid. 

THIERSCH'S  SOLUTION. 

Salicylic    acid    i/^  dram. 

Boric  acid 3  drams. 

Sterilized    water    1  quart. 

This  solution,  like  acetate  of  ahuninum  solution,  is 
non-toxic  and  non-irritant,  and  is  used  to  meet  the  same 
indications.  It  is  safe  and  useful  in  disinfecting  the 
mouth,  rectum  and  vagina,  preliminary  to  an  operation. 
It  is  the  solution  of  choice  in  irrigating  large  suppurat- 
ing cavities,  as  in  the  case  of  empyema,  suppurative  peri- 
tonitis and  synovitis.  It  comes  next  in  utility  to  acetate 
of  aluminum  solution  for  permanent  irrigation.  It  i? 
also  the  antiseptic  solution  of  choice  in  the  surgerv  of 
infants  and  young  children. 


56  A      nurse's      GUIDE 

ACETATE    OF   ALUMINUM    SOLUTION. 

Acetate  of  aluminnm  is  a  non-toxic,  non-irritating, 
mild  antiseptic. 

Its  use  is  limited  almost  entirely  to  the  treatment  of 
infected  wounds,  phlegmonous   inflammation   and   per- 
manent irrigation  of  suppurating  joints  and  large  ab 
scess  cavities. 

A  saturated  solution  can  be  used  freely  for  weeks  or 
months,  without  any  risk  of  intoxication  whatever.  Ace- 
tate of  aluminum  is  a  remedy  of  the  utmost  value  in  an- 
tiseptic surgery. 

ACETATE    OF    ALnilXLM    SOLUTION,     1    PER    CENT. 

Alum     24  grs. 

Acetate  of  lead 38  grs. 

Boiled  soft  water 1  quart 

A  compress  saturated  with  this  solution  and  applied 

directly  to  the  skin  in  dermatitis  of  all  kinds  promptly 

relieves  the  itching  and  burning,  prevents  the  spread  of 

the  disease,  and  promotes  the  process  of  resolution. 

CHLORID  OF  ZINC  SOLUTION. 

A  10  per  cent,  solution  of  clilorid  of  zinc  is  the 
strongest  weapon  in  the  attempt  to  transform  a  septic 
into  an  aseptic  wound.  The  wound  must  first  be  thor- 
oughly cleansed  and  dried  and  the  suppurating  surface 
freely  exposed  when  the  solution  is  applied  with  a  cot- 
ton swab;  after  a  few  minutes  the  excess  of  the  solu- 
tion is  washed  away  with  a  normal  salt  solution  and 
the  wound  covered  with  a  hot,  moist  antiseptic  com- 
press. 

The  chlorid  of  zinc  solution  penetrates  the  tissues 

deeper  than  any  of  the  other  antiseptic  solutions  and 

reaches  the  microbes  some  distance  from  the  surface  of 

the  wound. 

rin.oRiD  OF  zixc  solutiox,  10  per  cext. 

Chlorid   of   zinc    384  grs 

Distilled  or  soft  water,  boiled 8  ozs. 


Xf^ 


FOE     THE      0  P  E  R  A  T  I  X  G      ROOM  Oi 

BROMIN  SOLUTION. 

Bromin  is  a  powerful  antiseptic  and  was  used  quite 
extensively  in  the  concentrated  form  during  the  Civil 
War  in  the  treatment  of  hospital  gangrene. 

A  solution  of  one-fourth  of  1,  to  1  per  cent,  made 
with  potassium  bromid  is  a  valuable  deodorant  and  dis- 
infectant in  the  treatment  of  moist  gangrene  and  pro- 
fuse suppuration  when  used  as  an  antiseptic  in  moist 
dressings  or  for  irrigation  or  injection. 

BBOMIN   SOLUTION. 

Bromin    1  dram 

Potassium    bromid    2  drams 

Water     1  pint 

lODIN  SOLUTION. 

lodin  is  probably  the  most  potent  antipj^ogenic 
known.  The  1  per  cent,  solution  used  for  irrigatior 
has  to  be  diluted  one-half,  and  for  antiseptic  compresses 
it  should  not  be  used  in  greater  strength  than  one- 
fourth  of  1  per  cent.  lodin  solution  is  the  one  usually 
preferred  in  operations  for  open  tubercular  affections. 

lODIN  SOLUTION. 

lodin     1  dram 

Potassic  iodid   1  dram 

'    Sterilized   water 1  pint 

POTASSIUM    PERMANGANATE   SOLUTION. 

Potassium  permanganate  is  a  powerful  deodorant  and 
antiseptic.  It  has  been  used  for  a  long  time  in  solu- 
tions of  varying  strength  to  correct  the  odor  of  moist 
gangrene,  foid  ulcers  and  ulcerating  and  sloughing  ma- 
lignant  tumors. 

It  has  had  an  extensive  trial  in  conjunction  with  ox- 
alic acid  in  hand  disinfection,  a  method  which  origi- 
nated in  the  Johns  Hopkins  Hospital  and  which  is  still 
in  use  in  that  institution,  but  is  seldom  practiced  else- 
where. This  method  was  relied  upon  for  nearly  an  en- 
tire term  in  the  Rush  Medical  College  Clinic  in  prepar- 
ing the  hands,  but  did  not  prove  so  satisfactory  as  al- 
cohol, turpentine  and  bichlorid  of  mercury. 


58  A      X  U  R  S  E  ■■  S      GUIDE 

A  5  per  cent,  solution  is  used  for  hand  disinfection. 
In  the  strength  of  one-tenth  of  1,  to  1  per  cent,  it  is  a 
deodorant  that  can  be  emplo3^ed  .for  the  disinfection  of 
the  mouth  and  the  interior  of  fetid  abscesses. 

LYSOL  SOLUTION. 

Lvsol  solution  is  a  soapy  fluid  very  closely  resembling 
creolin  chemically.  Its  antiseptic  properties  become  ap- 
parent in  a  solution  of  1  or  2  per  cent.  The  toxic  effects 
are  much  milder  than  those  of  carbolic  acid,  and  as  it 
does  not  irritate  the  skin  it  is  often  employed  for  hand 
disinfection  and  for  preparing  the  cutaneous  surface 
for  operation. 

PHYSIOLOGIC    OR   NORMAL   SALT   SOLUTION. 

The  normal  salt  solution  is  prepared  by  dissolving 
six-tenths  of  1  per  cent,  of  sodium  chlorid  in  sterilized 
water.  A  teaspoonful  of  salt  to  a  quart  of  water  repre- 
sents approximately  the  strength  of  this  solution.  The 
solution  corresponds  in  its  degree  of  alkalinity  to  the 
serum  of  blood,  and  it  has  come  into  the  most  extensive 
use  in  aseptic  surgery.  In  cleansing  recent  wounds  it 
should  always  take  the  place  of  sterilized  water,  as  it 
does  not  damage  the  tissues  like  the  latter. 

PHYSIOLCGIC    OR   XORIIAL    SALT    SOLUTIO??^,    6/10    OF    1    PER    CE>'r. 

Sodium  chlorid   .368  grains 

Water,    sterilized    1  gal 

ALCOHOL. 

Alcohol  is  a  reliable  antiseptic  and  as  such  is  used 
at  the  present  time  the  world  over.  Its  anti-putrefac- 
tive effect  has  been  demonstrated  for  a  long  time  in  the 
museums  in  the  preservation  of  organic  material  of  all 
kinds.  Its  external  use  is  not  attended  by  any  danger 
from  absorption  in  toxic  quantities,  through  the  skin  or 
granulating  surfaces,  by  prolonged  or  extensive  applica- 
tion, and  it  is,  therefore,  applicable  for  hand  and  sur- 
face disinfection  under  all  circumstances,  regardless  of 
age  and  general  condition  of  the  patient. 


FOR     THE      OPERATING      ROOM  59 

It  does  not  lose  its  antiseptic  properties  by  age,  as 
is  the  case  with  many  of  the  more  potent  antiseptics. 
Its  solvent  action  on  fatty  substances  enhances  its  dis- 
infecting power. 

In  my  practice  the  local  use  of  alcohol  has  been  found 
very  effective  in  the  treatment  of  erysipelatous  inflam- 
mation and  other  forms  of  acute  superficial  lymphan- 
gitis. 

For  local  use  it  is  generally  diluted  one-half,  or  75 
per   cent. 

IODOFORM  EMTJLSIOIs^,   10  PER  CENT. 

Finely  triturated  iodoform,  one  ounce  or  one  part  by  weight. 

Glycerin,  nine  ounces  or  nine  parts  by  weight. 

Boil  glycerin,  bottle  and  cork  for  fifteen  minutes;  when  cool 
add  the  iodoform  powder  and  shake  well. 

One  of  the  most  important  precautions  in  handling 
antiseptic  solutions  is  to  read  carefully  the  labels. 

ANTISEPTIC  POWDERS. 

For  dry  dressings  in  the  treatment  of  small,  recent 
wounds  some  kind  of  antiseptic  powder  is  of  great  value 
in  preventing  infection.  The  antiseptics  in  powder 
form  may  not  destroy  the  microbes  on  the  surface  of 
the  wound  and  the  adjacent  skin,  but  they  will  prove 
efficient  in  inhibiting  their  growth. 

For  many  years  iodoform  was  used  almost  exclu- 
sively, but  the  odor,  expense  and  comparatively  feeble 
antiseptic  properties  of  this  drug  are  valid  objections 
to  its  general  use.  It  has  been  used  in  combination 
with  boric  acid,  and  the  results  have  been  equally  as 
satisfactory  as  when  the  pure  iodoform  was  used. 

IODOFORM -BORIC  POWDER. 

Iodoform    100  parts 

Boric    acid     50  parts 

To  be  effective,  the  antiseptic  powder  for  permanent 
dressing  should  resist  chemic  changes  to  a  maximum 
degree  on  exposure  to  atmospheric  air  or  when  brought 
in  contact  with  the  primary  wound  secretions. 

For  several  years  I  have  made  use  of  a  combination 


60  A      N  U  R  S  E  '  S      G  UI  D  E 

of  salicylic  and  boric  acids,  with  the  most  satisfactory 
results. 

The  following  is  the  formula  for  the — 

BORO-.S.\LICYLIC  ACID  POWDER. 

Boric  acid    4  drams 

Salicylic   acid    1  dram 

This  powder  is  particularly  well  adapted  for  the  treat- 
ment of  recent  gunshot  wounds. 

ANTISEPTIC  OINTMENTS. 

The  typical  antiseptic  dressing  has  reduced  the  use 
of  salves  in  surgery  to  within  very  narrow  limits.  All 
the  ointments  in  use  at  the  present  time  contain  one  or 
more  antiseptics,  and  are  employed  as  a  primary  wound 
dressing  in  the  treatment  of  small  wounds,  especially  of 
the  lips  and  face,  to  protect  granulating  surfaces  and 
occasionally  as  a  protection  for  skin-grafts. 

The  French  surgeons  are  very  partial  to  what  they 
call  the  Antiseptic  Pomade : 

Antipyrin     5  parts 

Boric  acid   5  parts 

Iodoform     1  part 

Vaselin     50  parts 

As  a  protection  for  granulating  surfaces,  and  as  a 
dressing  after  harelip  operations  and  small  wounds  of 
the  face.  I  have  found  the  following  to  be  very  effica- 
cious : 

BORO-S.\LICYLIC  OIXTMENT. 

Boric  acid  I/2  dram 

Salicylic  acid    10  grains 

Glycerin  ointment   1  ounce 

CHLORAL  HYDRATE  OINTMENT. 

Chloral    hydrate    o  parts 

Gum    acacia    5  parts 

PoAvdered  camphor    5  parta 

Vaselin     50  parts 

The  last-named  ointment  is  a  soothing  application  in 
all  forms  of  dermatitis  and  burns. 


FOR     THE      OPERATING      ROOM  61 

UNGUENTUM  CREDE. 

The  silver  ointment  of  Crede  is  said  to  penetrate  the 
intact  skin  and  exert  its  antipyogenic  effect  on  the 
bacteria  in  the  tissues.  It  has  been  used  with  success 
not  only  in  lymphangitis  of  the  skin,  but  also  in  deep- 
seated  phlegmonous  inflammation.  It  is  not  essential, 
according  to  Crede,  that  the  inunction  should  be  made 
directly  over  the  affected  part  in  order  to  secure  its 
antipyogenic  effect  on  infected  processes  distant  from 
the  surface  of  the  skin. 


CHAPTER  VIII. 


PREPARATION   FOR   MAJOR  AND  MINOR   OPERATIONS. 

Ample  experience  has  demonstrated  that  infection 
by  contact  is  to  be  feared  much  more  than  infection  by 
microbes  suspended  in  the  air.  It  is  generally  con- 
ceded that  operation  wounds  are  most  frequently  in- 
fected by  contact  with  the  hands  of  the  operator  or  his 
assistants.  The  risk  of  infection  increases  with  the 
number  of  assistants,  and  this  statement  applies  with 
special  force  to  new  and  inexperienced  assistants,  as  is 
the  case  with  college  clinics  in  our  coimtry,  in  which 
the  assistants  serve  for  only  three  or  four  months  at  a 
time. 

Since  Eberth  discovered  numerous  bacteria  in  nor- 
mal perspiration  in  1875,  it  has  been  found  that  the 
surface  of  the  body  is  inhabited  by  a  whole  flora  of 
pathogenic  microbes.  They  are  most  numerous  upon 
the  hairy  parts  of  the  skin,  in  the  folds  and  crevices, 
in  the  outlets  of  the  glandular  appendages  and  espe- 
cially in  the  subimgual  spaces  of  the  fingers. 

Careful  hand  disinfection  is  an  essential  prerequisite 
to  aseptic  surgery.  The  hands  of  the  assistants  and 
nurses  should  be  as  carefully  disinfected  and  kept  so 
as  those  of  the  operator.  Each  hospital  has  its  own 
method  of  rendering  aseptic,  hands  and  arms,  also  for 
the  sterilization  of  instruments  and  the  disinfection  of 
the  field  of  operation  or  injury. 

HAND   DISINFECTION. 

First. — Scrub  for  fifteen  minutes  with  hot  water  and 
potash  soap,  hands  and  arms  to  elbows. 

Second. — Trim,  clean  and  scrape  nails,  scrub  again 
in   turpentine,   again   in  hot  water   and  potash   soap,. 


FOE     THE      OPERATING      EOOM  63 

rinse  with  clear  hot  water  to  remove  soap.    (Soap  de- 
stroys the  antiseptic  properties  of  bichlorid.) 

The  finger  nails  should  be  trimmed  with  German 
nail  scissors.  The  metallic  nail  cleaner  should  never  be 
used  as  it  tears  up  the  epidermis  and  irritates  the  under 
surface  of  the  nail. 


German  Nail  Scicsors. 

The  orange  stick  used  by  manicures  is  the  proper 
instrument  for  cleaning  out  the  ungual  folds  and  sub- 
ungual spaces.  It  is  flat  on  one  end  and  pointed  on 
the  other.  In  using  it  the  end  of  the  stick  used  is  fre- 
quently dipped  in  peroxid  of  hydrogen. 

Orange   Stick   Nail   Cleaner. 

Third.— Alcohol. 

Fourth. — Immerse  in  bichlorid  solution,  1 :1000,  for 
five  minutes,  using  nail  brush,  and  finally  wash  thor- 
oughly with  alcohol. 

The  hands  thus  disinfected  are  surgically  clean; 
therefore,  nothing  should  be  touched  which  is  not  asep- 
tic. 

If  the  operator  calls  for  potassium  permanganate, 
further  preparations  are  necessary,  such  as  the  follow- 
ing: 

Provide  four  basins,  one  containing  5  per  cent,  solu- 
tion of  potassium  permanganate;  the  second,  sterilized 
water;  the  third,  a  saturated  solution  of  oxalic  acid, 
and  the  fourth,  a  1:1000  solution  of  bichlorid. 

First. — The  hands  and  arms  to  the  elbows  are  soaked 


64  A      nurse's      GUIDE 

in  the  potassium  permanganate  solution  until  the  skin 
becomes  brown. 

Second. — The  hands  and  arms  are  washed  in  sterile 
water. 

Third. — The  stain  is  thoroughly  removed  from  the 
skin  by  scrubbing  with  the  oxalic  acid  solution. 

Fourth. — The  hands  are  washed  in  the  sublimate 
solution. 

Fifth. — Alcohol  is  freely  poured  over  the  hands. 

Adequate  preparations  for  hand  disinfection  must 
be  made  in  the  treatment  of  all  open  injuries,  for  all 
operations  surgical,  gynecologic  and  all  obstetric  ma- 
nipulations. 

USE  AND  CARE  OF  RUBBER  GLOVES. 

Experimental  research  and  clinical  experience  have 
demonstrated  that  all  Imown  methods  of  hand  disinfec- 
tion have  failed  in  rendering  the  skin  absolutely  asep- 
tic; hence  the  use  of  cotton  and  rubber  gloves. 

Mikulicz  was  the  first  to  recommend  the  use  of  steril- 
ized cotton  gloves,  and  has  continued  their  use  up  to 
the  present  time. 

Very  often  as  many  as  three  or  four  pairs  are  used 
in  the  same  operation,  and  as  the  cotton  gloves  do  not 
give  the  same  protection  against  infection  as  the  rub- 
ber gloves,  the  latter  are  in  more  general  use.  In  their 
>care  observe  the  following: 

Wash  gloves  thoroughly  in  hot  water  and  potash 
soap  and  rinse  in  clear  water. 

Examine  each  one  carefully  by  filling  with  water, 
and  those  found  to  be  punctured  or  torn  lay  aside  to 
be  repaired. 

Wrap  gloves  in  a  towel  and  boil  in  clear  water  for 
five  minutes.  With  surgically  clean  hands  remove  from 
the  sterilizer  and  place  in  an  aseptic  basin  containing 
sterilized  water. 

Upon  a  table  that  has  been  disinfected  and  covered 
with  a  sterilized  sheet  place  the  gloves  and  dry  each  one 


FOR     THE      OPERATING      ROOM  65 

with  an  aseptic  towel,  after  which  each  glove  should  be 
well  powdered  with  sterilized  talcum  powder,  which 
should  be  rubbed  over  with  the  hand,  care  being  taken 
to  turn  each  one  inside  out  so  that  both  sides  be  well 
powdered. 

To  preserve  asepticity  for  future  use  wrap  each  pair 
of  gloves  in  a  sterilized  towel,  place  in  a  glass  jar  and 
keep  in  a  cool  place. 

Before  putting  on  the  gloves  the  hands  should  be 
thoroughly  dried  and  well  powdered. 

To  prevent  tearing,  turn  the  cuff  of  the  glove  back 
over  the  palm  and  slip  the  hand  in. 

If  the  gloves  become  sticky  during  the  operation 
wash  in  normal  salt  solution,  dry  with  an  aseptic  towel 
and  powder  again. 

Alcohol,  ether  or  carbolic  acid  should  not  be  used  to 
disinfect  rubber  gloves,  as  these  antiseptics  render 
them  sticky. 

If  the  gloves  worn  by  the  operator  or  his  assistants 
become  punctured  or  torn,  sterilized  finger  cots  should 
be  in  readiness  and  put  on  immediately.  This  precau- 
tion will  prevent  the  danger  of  contaminating  the 
wound. 

The  hands  should  be  as  thoroughly  disinfected  as  if 
the  operation  were  to  be  performed  without  the  use  of 
gloves,  and  if  it  be  necessary  to  remove  them  during 
the  operation  the  hands  should  be  again  subjected  to  a 
thorough  chemical  disinfection. 

To  avoid  the  danger  of  tearing  the  gloves  while  re- 
moving them  turn  the  cuff  down  upon  the  hand,  and 
thus  they  can  be  rolled  with  ease  over  the  fingers. 

REPAIR  OF  TORN  AND  PUNCTURED  RUBBER   GLOVES. 

Procure  rubber  cement  and  rubber  dam  used  for  re- 
pairing rubber  gloves,  also  test  tubes  of  various  sizes 
upon  which  to  place  the  punctured  or  torn  finger,  and 
wash  with  alcohol  or  ether. 

Cut  a  round  or  square  piece  of  the  rubber  dam  large 


66  A     nurse's      GUIDE 

enough  to  cover  the  punctured  or  torn  finger,  then  ap- 
ply the  cement  with  a  wooden  spatula,  immediately 
placing  the  prepared  piece  of  rubber  dam  over  the 
area,  holding  it  firmly  in  position  until  it  adheres  to 
the  glove. 

Gloves  should  not  be  boiled  for  at  least  twelve  hours 
after  having  been  repaired. 

The  bottle  containing  the  rubber  cement  should  not 
be  left  uncovered  longer  than  necessary,  as  the  cement 
contains  benzine  and  other  volatile  substances,  and  it 
should  not  be  forgotten  that  these  are  highly  inflamma- 
ble and,  besides,  rapid  evaporation  takes  place  on  ex- 
posure to  the  air. 

DISINFECTION  OF  FIELD  OF  OPERATION. 

By  surface  disinfection  is  meant  the  process  re- 
sorted to  for  the  preparation  of  the  field  of  operation. 
The  same  means  are  resorted  to  in  order  to  render  the 
skin  aseptic  as  in  hand  disinfection,  with  this  differ- 
ence, however,  that  in  the  disinfection  of  the  hairy 
skin  we  can  resort  to  more  thorough  means  of  mechani- 
cal removal  of  microbes  from  its  surface  by  the  use  of 
the  razor.  The  careful  and  thorough  use  of  the  razor 
not  only  removes  the  infected  hair,  but  likewise  scrapes 
away  the  superficial  epithelial  layers  of  the  skin  soft- 
ened by  the  use  of  hot  water  and  potash  soap. 

Potash  soap  is  given  the  preference  over  the  ordinary 
soda  soap,  because  of  its  well-known  deeper  penetra- 
tion of  the  epidermis  of  the  skin.  The  extent  of  shaving 
and  disinfection  of  the  field  of  operation  must  neces- 
sarily vary  according  to  the  site  and  extent  of  the  in- 
tended operation. 

A  safe  rale  to  follow  is  to  make  the  disinfection,  if 
anything,  too  extensive.  Thus  in  operations  of  any 
magnitude  upon  the  scalp  and  large  wounds  of  this 
structure  and  all  operations  on  the  skull  and  its  con- 
tents the  entire  scalp  must  be  shaved  and  disinfected. 


FOE     THE      OPERATING      ROOM  67 

In  operations  upon  the  breast,  the  axilla  and  half  of 
the  chest  must  be  prepared,  and  if  the  glands  of  the 
neck  are  involved  the  entire  neck  must  be  included  in 
the  field  of  operation. 

In  amputations  of  the  foot  and  lower  third  of  the 
leg  the  disinfection  must  extend  as  far  as  the  knee,  and 
in  all  higher  amputations  it  should  include  the  whole 
limb  and  the  corresponding  side  of  the  pelvis. 

In  all  abdominal  operations  below  the  umbilicus,  the 
pubes  must  be  shaved  and  the  surface  disinfection 
must  include  the  whole  anterior  surface  and  both  sides 
as  far  as  the  breasts. 

In  operations  on  the  stomach,  liver  and  bile  ducts, 
the  field  of  operation  extends  from  the  pubes  to  the 
breasts. 

A  general  warm  bath,  with  liberal  use  of  potash  soap 
and  a  scrubbing  brush,  must  precede  disinfection  of 
field  of  operation  in  all  abdominal  and  pelvic  opera- 
tions, including  hernia  and  varicocele. 

In  operations  upon  parts  of  the  body  very  difficult  to 
disinfect,  such  as  the  scalp,  palm  of  the  hand  and  sole 
of  the  foot,  it  is  advisable  to  apply  for  two  or  three 
hours  a  potash  soap  poultice  for  the  purpose  of  macer- 
ating the  thick  epithelial  layers  of  the  epidermis,  pre- 
paratory to  the  chemical  disinfection  of  the  surface. 

After  the  disinfection,  the  field  of  operation  is  cov- 
ered with  a  warm  compress  of  gauze  wrung  out  of  a 
1:3000  or  1:5000  solution  of  mercuric  bichlorid,  over 
which  are  placed  gutta-percha  tissue  and  cotton  pad, 
held  in  place  by  a  bandage,  until  the  final  disinfection, 
which  is  made  immediately  before  the  administration 
of  the  anesthetic. 

In  the  course  of  disinfection,  after  thorough  scrub- 
bing with  hot  water  and  potasli  soap,  efforts  are  made 
to  reach  the  glands  of  the  skin,  always  hiding  places  of 
pathogenic  microbes.  This  is  effected,  to  a  certain  ex- 
tent, by  strong  disinfectants  which  have  the  power  of 
dissolving  fat  and  penetrating  the  skin   deeply.    The 


68  anurse'sguide 

agents  in  general  use  for  this  purpose  are  alcohol, 
ether,  spirits  of  turpentine  and  benzine.  In  my  own 
practice,  I  give  turpentine  the  preference.  Alcohol  is 
universally  used  in  hand  and  surface  disinfection  and 
should  never  be  absent  from  the  operating  room. 

In  preparing  mucous  cavities  and  tracts  for  opera- 
tion, the  difficulties  of  procuring  an  appjroximately 
aseptic  condition  are  greatly  enhanced.  For  reasons 
that  do  not  call  for  any  extended  explanation,  all 
strong  antiseptic  solutions  are  not  applicable  in  such 
cases.  The  mucous  membranes  are  active  absorbing 
surfaces,  and  the  use  of  solutions  of  carbolic  acid,  mer- 
curic bichlorid  and  other  potent  antiseptics  are  fraught 
with  danger.  The  free  use  of  any  of  these  agents  in 
the  vagina,  uterus  or  rectum  has  frequently  resulted  in 
serious  poisoning  and,  not  in  a  few  instances,  in  death. 

The  mechanical  part  of  the  disinfection  is  also  much 
less  satisfactory  than  in  preparing  the  skin  for  opera- 
tion. Disinfection  of  the  mouth  should  invariably  pre- 
cede the  use  of  a  general  anesthetic,  as  in  doing  so  the 
danger  of  inflammatory  complications  of  the  air  pas- 
sages following  anesthetization  is  greatly  diminished. 
For  this  purpose  and  to  prepare  the  cavity  of  the  mouth 
for  operation,  the  safest,  most  efficient  and  agreeable 
solution  consists  of  a  saturated  solution  of  boric  acid, 
with  the  addition  of  a  teaspoonful  of  Listerin  to  each 
ounce. 

The  solution  is  applied  to  the  mucous  lining  of  the 
mouth  with  a  soft  tooth  brush  or  cotton  swab.  In 
grave  operations,  such  as  excision  of  the  superior  or 
inferior  maxilla  and  amputation  of  the  tongue,  the 
employment  of  this  solution  is  preceded  by  thorough 
cleansing  of  the  teeth,  and  the  mucous  membrane  is 
pwabbed  with  peroxid  of  hydrogen. 

In  operations  upon  the  rectum,  a  brisk  cathartic  and 
high  rectal  enema  are  given,  followed  by  irrigation  and 
swabbing  with  Thiersch's  solution. 

Vaginal     rlisinfection    is    more    satisfactory.     After 


FOR     THE      OPERATING      ROOM  69 

thorough  scrubbing  with  hot  water  and  potash  soap, 
peroxid  of  hydrogen  and  pure  alcohol  are  relied  upon 
in  the  chemical  disinfection  of  the  mucosa.  The  vaginal 
disinfection  is  preceded  by  shaving  and  disinfection  of 
the  external  genitals. 

Catheterization  should  always  be  preceded  by  disin- 
fection of  the  meatus  with  alcohol  or  a  1 :1000  solution 
of  mercuric  bichlorid. 


CHAPTER  IX. 


STERILIZATION  AND  DISINFECTION. 

Both  of  these  terms  are  employed  to  indicate  the  use 
of  measures  intended  to  remove,  destroy  o^r  render 
harmless  microscopic  vegetable  parasites,  germs  or  mi- 
crobes, which  are  the  cause  of  all  infective  processes 
and  infective  diseases.  By  sterilization  is  meant  the 
absolute  absence  of  pathogenic  microbes  from  instru- 
ments, solutions  or  dressing  materials — a  condition  at- 
tained vrith  any  degree  of  certainty  only  by  exposing 
these  articles  to  a  degree  of  heat  sufficient  to  destroy 
bacterial  life.  Dry  heat,  steam  and  boiling  are  the 
processes  which  effect  sterilization  if  the  articles  are 
exposed  to  the  germ-destroying  effect  of  heat  for  a 
sufficient  length  of  time.  Steam,  oversteam  and  boiling 
are  now  the  most  common  and  widely  accepted  means 
of  effecting  sterilization. 

The  term  disinfection  applies  more  particularly  to 
the  means  and  measures  resorted  to  in  rendering  in- 
fected wounds  aseptic  and  in  freeing  the  hands  and 
the  field  of  operation  of  all  harmful  bacteria  as  nearly 
as  can  be  done  by  mechanical  and  chemical  processes. 

The  use  of  the  razor,  potash  soap  and  warm  water  is 
a  preliminary  mechanical  means  to  prepare  the  way 
for  a  thorough  disinfection  by  chemical  agents,  which 
are  known  to  destroy  or  inhibit  the  growth  of  microbes, 
of  which  the  most  important  are  carbolic  acid,  corrosive 
sublimate,  iodin,  lysol,  creasol  and  alcohol. 

Physical  sterilization  is  sterilization  by  heat.  Dry 
heat,  heated  dry  air,  ranges  in  sterilizing  power  above 
the  chemical  means,  but  below  hot  water  and  steam,  as 
dry  heat  has  very  little  penetrating  power. 

Bacteria  which  do  not  contain  spores  are  destroyed 
in  dry  heat  after  an  hour  and  a  half  at  a  temperature 


FOR     THE      OPERATING      ROOM  71 

of  212  degrees  F.,  while  three  hours'  exposure  at  a 
temperature  of  284  degrees  F.  is  required  to  kill  spores. 
Moist  heat  is  the  best  germicide. 

The  thermal-death-point  of  surgical  bacteria,  which 
practically  means  pyogenic  cocci  which  are  not  spore- 
bearing  and  the  bacillus  of  tuberculosis  and  its  spores, 
is  correspondingly  low  when  they  are  exposed  to  moist 
heat.  The  pyogenic  cocci  are  all  killed  inside  of  ten 
minutes  at  a  temperature  of  about  150  degrees  F., 
while  the  tubercle  bacilli  and  their  spores  are  de- 
stroyed at  a  temperature  of  212  degrees  F.  in  five  min- 
utes. 

Boiling  for  five  minutes  at  a  temperature  of  212  de- 
grees F.  seems,  therefore,  to  hold  good  for  all  practical 
purposes.  Moist  heat,  as  steam,  is  another  excellent 
germicide,  as  it  acts  like  hot  water  of  the  same  tem- 
perature and  it  can  be  used  where  boiling  is  not  prac- 
ticable. The  germicidal  properties  of  steam  depend 
upon  its  moisture,  on  its  temperature  and  on  its  ex- 
pulsion of  air  contained  in  the  articles  to  be  sterilized. 
Steam  of  a  higher  temperature  than  the  boiling  point 
is  obtained  either  by  conducting  the  steam  evolved 
through  heated  pipes  (called  superheated  steam)  or 
by  evolving  steam  under  pressure  (high  steam). 

All  known  pathogenic  bacteria  and  their  spores  are 
destroyed  in  low  steam  at  a  temperature  of  212  degrees 
F.  maintained  for  five  minutes.  Low  steam  at  a  tem- 
perature of  212  degrees  F.  is,  therefore,  surgically  per- 
fect and  easily  generated. 

Concerning  the  moisture,  it  is  a  well-established  fact 
that  the  condensation  of  steam  in  the  articles  to  be 
sterilized  is  a  most  important  factor  in  the  success  of 
sterilization.  The  exact  cause  of  this  is  not  fully  un- 
derstood. Wet  steam  will  sterilize,  but  dry  steam  will 
not.  Wet  or  saturated  steam  is  steam  as  delivered  from 
a  mass  of  water  and  holding  water  in  suspension  me- 
chanically or  as  vapor.  This  is  the  sterilizino-  steam. 
Dry  or  superheated  steam   (steam  gas)   holds  "little  or 


72 


A      NURSE     S      GUIDE 


no   water   in   suspension.     This    is   the   non-sterilizing 
steam.   It  corresponds  in  effectiveness  with  dry  heated  air. 

SPORES. 

The  spores  of  bacteria  represent  the  seeds  of  flower- 
ing plants.  Each  spore  develops  into  a  bacterium,  and 
thus  one  crop  after  another  is  produced.  Most  of  the 
bacilli  multiply  by  spores.  The  spores  are  much  more 
refractory  to  destructive  agents  than  the  microbes  into 
which  they  develop.  This  is  particularly  true  of  the 
bacillus  of  tuberculosis  and  tetanus. 

STERILIZATION  OF  DRESSING. 

Wrap  in  a  separate  towel,  cotton,  gauze,  sponges, 
laparotomy  compresses,  sheets,  bandagas,  doctors' 
gowns,  nurses'  gowns,  and  sterilize  thirty  minutes  with 
moist  heat  and  thirty  minutes  with  dry  heat.  Note  the 
time  after  the  water  has  reached  the  boiling  point. 

The  O'Neill  aseptic  dressing  jar  is  a  most  convenient 
receptacle  for  preserving  the  asepticity  of  sterilized 
surgical  supplies. 


O'NeiU's  Aseptic   Glass  Dressing  Jar. 

The  usual  laparotomy  dressing  consists  of  one  yard 
of  sterilized  gauze  (hygroscopic)  loosely  applied  and  a 


FOE     THE      OPERATING      ROOM  73 

strip  of  absorbent  cotton,  eleven  by  fifteen  inches,  cov- 
ered with  sterilized  gauze.  This  dressing  is  retained  in 
place  by  two  or  more  aseptic  adhesive  plaster  strips. 
For  the  majority  of  wounds  in  abdominal  sections  a 
simple  abdominal  bandage  held  in  place  by  perineal 
straps  is  required,  but  for  hernia  operations,  or  in  any 
case  where  the  incision  is  low  in  the  abdomen,  a  gauze 
roller  bandage  is  preferred.  If  the  surgeon  calls  for 
collodion  dressing  give  a  three-inch  strip  of  gauze  and 
collodion  in  a  small  glass  with  a  camel's-hair  brush; 
also  a  thin  film  of  cotton,  which  is  placed  over  the 
gauze.  When  the  wound  is  sealed  with  the  collodion 
apply  the  usual  laparotomy  dressing. 

ASEPTIC   ADHESIVE   PLASTER  STRIPS. 

Aseptic  adhesive  plaster  strips  used  for  holding  in 
place  abdominal  or  other  dressings  are  found  preferable 
to  the  ordinary  long  adhesive  strips,  as  the  sterilized 


Aseptic   Adhesive   Plaster   Strip. 

bleached  muslin  strips  occupy  the  space  over  the  dress- 
ing, the  adhesive  plaster  being  attached  to  each  end. 
In  removing  the  dressing  the  adhesive  strips  need  not 
be  disturbed  until  no  longer  required,  thus  sparing  the 
patient  the  discomfort  that  is  caused  by  their  removal 
at  each  dressing. 

To  remove  the  dressing  the  muslin  must  be  cut  in 
the  center  and  laid  back  until  the  dressing  is  replaced, 
when  the  ends  of  the  muslin  are  again  brought  in  posi- 
tion over  the  dressing  and  secured  with  safety  pins. 

The  strip  consists  of  a  piece  of  sterilized  bleached 
muslin  fifteen  to  eighteen  inches  in  length  and  three 
inches  in  width,  to  each  end  of  which  is  firmly  stitched 
a  piece  of  adhesive  plaster,  five  by  three  inches,  which 
should  be  cut  in  two  places,  (A)  within  one  inch  of  its 


74  A      NU  use's      GUIDE 

attachment  to  the  muslin,  making  it  fan-shaped,  (B) 
as  is  shown  in  figure  above.  Applied  in  this  manner, 
the  irritation  caused  by  adhesive  plaster  is  decreased. 

INSTRUMENTS. 

Place  in  the  sterilizer  (common  wash  boiler  will  an- 
swer) instrument  trays,  basins,  pitchers,  etc.,  and  boil 
for  fifteen  minutes  in  a  1  per  cent,  solution  of  carbon- 
ate of  soda.  Disinfect  the  tablas  with  carbolic  acid,  3 
per  cent.,  or  with  alcohol,  cover  the  floor  of  trays  with 
sterilized  gauze,  l-eserving  one  tray  and  an  aseptic 
brush  for  soiled  instruments;  cover  the  bottles  with 
sterile  gauze,  and  handle  corks,  covers,  etc.,  with  an 
aseptic  gauze  sponge. 

A  celebrated  surgeon  remarks :  "Before  an  opera- 
tion it  is  comparatively  easy  to  render  everything  sur- 
gically clean,  but  it  is  extremely  difficult  to  keep  them 
so  during  the  operation." 

Place  in  an  instrument  sterilizer,  instruments,  pins 
and  needles,  and  boil  for  fifteen  minutes  in  1  per  cent, 
solution  of  soda  carbonate.  Knives  and  scissors  are 
boiled  for  five  minutes  and  placed  in  a  glass  dish  with 
alcohol  (heat  dulls  cutting  edges).  All  instruments 
are  injured  by  corrosive  sublimate. 

When  instruments  are  sufficiently  sterilized,  the 
tables,  trays  and  hands  having  been  previously  pre- 
pared, remove  cover  from  sterilizer  with  an  aseptic 
towel  and  arrange  instruments  in  the  trays  in  such 
order  that  each  one  may  be  readily  found  when  called 
for  by  the  surgeon.  Before  the  operation  the  needles 
are  threaded  and  kept  in  alcohol.  Arrange  on  the  table 
a  bottle  of  alcohol,  bottle  of  collodion,  aseptic  glass, 
camel's  hair  brush,  iodoform  powder,  boro-salicylic 
acid,  4:1,  small  glass  jar  with  sterilized  safety  pins, 
glass  jar  with  three  and  eight-inch  strips  of  iodoform 
gauze  and  a  glass  dish  for  knives  and  scissors. 

Unless  intimately  acquainted  with  the  surgeon's 
methods,  it  is  well  to  have  him  inspect  before  the  opera- 


FOR     THE      OPERATING      ROOM  75 

tion  the  instruments  and  sutures  which  you  have  pre- 
pared. Instruments  which  have  become  contaminated 
during  an  operation  must  not  be  used  again  until  they 
have  been  sterilized  by  boiling. 

PREPARATION   OF   MEDICATED    DRESSING   MATERIAL. 

lODOFOEM  GAUZE. 

Cut  the  gauze  in  lengths  of  five  yards  and  sterilize 
for  thirty  minutes  before  medication.  Handle  with  sur- 
gically clean  hands.  Sheets,  towels  and  everything  com- 
ing in  contact  with  the  gauze  must  be  aseptic. 

SOLUTION  NO.  1. 

?,!yf""     y.gallon 

.^^'^*er     y^  gallon 

Mix  and  boil  for  fifteen  minutes.    When  cold  pour  into  a 
large  stone  jar  which  has  been  rendered  aseptic. 

SOLUTION  NO.  2. 

lo'io^O'""^     3  ounces 

^  ^^oJiol     Ipint 

_  Note.— The  iodoform  is  not  perfectly  soluble  in  this  quan- 
tity of  alcohol;  however,  it  answers  the  purpose. 

Add  No.  2  to  No.  1,  and  while  stirring  briskly  im- 
merse thirty  ounces  or  thirty  yards  of  gauze  (on  an  av- 
erage a  yard  of  gauze  weighs  an  ounce)  ;  continue  the 
motion  until  the  gauze  is  thoroughly  and  evenly  im- 
pregnated with  the  iodoform;  otherwise  the  latter  will 
sink  to  the  bottom  and  the  gauze  will  not  retain  the 
entire  quantity.  Then  pass  the  gauze  through  an  asep- 
tic wringer;  that  is,  one  that  has  been  scrubbed  with 
potash  soap,  rinsed  with  sterile  water  and  carbolic  acid, 
5  per  cent.  Fold  the  gauze,  roll  it  tightly,  wrap  in' 
waxed  paper  and  seal.   Preserve  in  a  stone  jar. 

If  more  than  thirty  (30)  yards  of  gauze  is  to  be  pre- 
pared, add  to  the  remaining  solution,  if  necessary,  one 
ounce  of  glycerin  and  three  ounces  of  iodoform'  dis- 
solved in  one  pint  of  alcohol,  as  this  is  absorbed  by  each 
thirty  yards  of  gauze.   Then  proceed  as  described  above. 

To  improve  the  color  of  the  iodoform  solution  add 
about  one  dram  of  tincture  of  curcuma  for  every  thirty 
yards  of  gauze. 


76  A      nurse's      GUIDE 

FORMULA    FOR    TINCTURE    OF    CURCUMA. 

Powdered  curcuma   4  ounces 

Proof  spirit   1  pint 

Let  stand  till  clear.   Pour  off  clear  liquid.    Continue 

to  add  proof  spirit  till  all  color  is  extracted. 

CORROSIVE  SUBLIMATE  GAUZE. 

Corrosive  sublimate   10  grains 

Glycerin  Vz   pint 

Distilled  water    32  ounces 

Sodium   chlorid    1/2  ounce 

Citric  acid   1  ounce 

Mix  well. 

This  solution  will  moisten  sixty  yards.  Cut  in  lengths 
of  five  yards  each  and  soak  for  some  time  to  thoroughly 
saturate  the  gauze,  fold  and  wrap  in  waxed  paper,  mak- 
ing air  tight,  and  place  in  a  tin  box. 

CARBOLIZED  GAUZE. 

Carbolic  acid    3  ounces 

Glycerin    24  ounces 

Distilled  water    32  ounces 

This  solution  will  moisten  sixty  yards  of  gauze.    Cut 

in  five-yard  lengths,  fold,  roll,  wrap  in  waxed  paper  and 

keep  in  air-tight  tin  boxes, 

ADHESIVE  ANTISEPTIC  GAUZE, 

Adhesive  gauze  is  frequently  used  in  arresting  surface 
oozing,  as  the  mixture  with  which  the  gauze  is  impreg- 
nated is  not  only  antiseptic,  but  also  adhesive. 

Carbolic  acid 1  part 

Resin    5  parts 

Paraffin    7  parts 

SALIOYLATED   GAUZE,  TEN   PER    CENT.   SOLUTION, 

Salicylic   acid    5  ounces 

Alcohol     24  ounces 

Glycerin    6  ounces 

Sterilized  water   G  ounces 

First. — Dissolve  salicylic  acid  in  alcohol. 

Second. — Boil  glycerin  and  water  for  fifteen  min- 
utes and  add  to  the  above  solution. 

This  quantity  will  medicate  sixty  yards  of  gauze, 
which  should  be  previously  cut  in  five-yard  lengths  and 
sterilized. 


FOK     THE      OPERATING      ROOM  77 

Place  in  an  aseptic  glass,  granite  or  glazed  earthen 
jar  and  let  stand  for  twenty-four  hours  that  the  gauze 
may  become  thoroughly  moistened. 

Handle  with  surgically  clean  hands,  roll  tightly, 
wrap  in  waxed  paper  and  seal. 

SALICYLATED   COTTON,  TEN  PER  CENT. 

The  above  solution  is  also  used  in  preparing  salicy- 
lated  cotton.  For  each  one-pound  roll  of  absorbent  cot- 
ton the  following  quantity  will  be  required: 

Salicylic  acid   2  ounces 

Alcohol    2Vo  ounces 

Glycerin     12  drams 

Sterilized  water  12  drams 

The  cotton  should  be  sterilized,  and  with  surgically 
clean  hands  spread  upon  a  table  that  has  been  pre- 
viously disinfected,  and  the  entire  quantity  of  the  solu- 
tion should  be  applied  by  lightly  sprinkling  it  over  the 
cotton,  which  is  then  tightly  and  evenly  rolled  that  it 
may  become  thoroughly  impregnated.  Wrap  in  waxed 
paper  and  seal. 

BOEATED  COTTON. 

Immerse  the  absorbent  cotton  in  a  saturated  solution 
of  boric  acid.  Wring  out  and  dry  slowly.  Do  not  open 
the  roll  of  cotton  until  after  it  has  been  saturated  thor- 
oughly in  the  boric  acid. 

PREPARATION  OF  WAXED  OR  PARAFFIN  PAPER. 

Melt  the  wax  or  paraffin  (the  latter  will  answer  and 
is  much  cheaper),  and,  while  pouring  it  on  the  paper, 
iron  evenly  with  a  hot  flatiron. 

A  more  rapid  and  better  method  is  to  pass  the  paper 
immediately  after  its  immersion  in  the  melted  material 
through  the  mangle  in  the  laundr}^,  being  careful  not 
to  have  the  rollers  too  hot,  as  in  this  event  the  paper 
would  be  scorched. 

For  sealing  the  rolls  of  gauze,  wax  is  preferable  to 
paraffin. 

Note. — Waxed  or  paraffin  paper  also  serves  an  ex- 
cellent purpose  as   a   protective  in  the  application  of 


78  A     nurse's     GUIDE 

stupes  or  poultices   and   is  much  less   expensive  than 
oiled  silk  or  gutta-percha  tissue. 

Waxed  paper  is  disinfected  by  immersing  for  five 
minutes  in  a  2  per  cent,  solution  of  formalin,  after 
which  each  sheet  is  dried  with  a  sterilized  towel,  rolled 
separately  and  placed  in  an  aseptic  glass  jar. 

DRAINAGE  AND  DRAINAGE  MATERIAL. 

Drainage  is  used  to  prevent  the  accumulation  of 
serum,  pus  or  wound  secretions.  This  is  effected  by 
means  of  tubular  or  capillary  drains. 

Tubular  Drains. — Tubular  drains  are  made  of  per- 
forated rubber  and  glass  tubing.  A  perforated  glass 
tube  loosely  packed  with  gauze  constitutes  a  combined 
tubular  and  capillary  drain. 

Capillary  Drainage. — Capillary  drainage  is  made 
with  strips  of  iodoform  gauze,  hygroscopic  gauze,  or  a 
skein  of  catgut  or  horse  hair. 

Mikulicz  Drain. — The  Mikulicz  drain  is  a  capillary 
drain  on  a  large  scale  and  consists  of  a  square  piece  of 
iodoform  gauze  of  requisite  size,  placed  in  a  cavity,  and 
filled  with  narrow  strips  of  plain  gauze  until  the  requi- 
site degree  of  compression  is  secured.  This  drain  is 
used  where  there  is  parenchymatous  oozing — it  serves 
as  a  tampon  to  arrest  bleeding  and  also  acts  as  a  capil- 
lary drain.  ' 

CIGARETTE  DRAIN. 

The  cigarette  drain  is  made  by  inserting  hygroscopic 
gauze  in  a  tube  made  of  gutta-percha  tissue. 


Cigarette  Drain. 


The  cementing  of  the  margins  of  the  gutta-percha  is 
done  by  the  careful  use  of  chloroform,  as  an  excess  of 
chloroform    dissolves    the    material.     The   gutta-percha 


FOR     THE      OPERATING      ROOM  79 

tube  should  be  fenestrated,  and  the  gauze  made  to  pro- 
ject a  slight  distance  from  the  openings  of  the  tube. 

SURFACE  DRAIN. 
The  so-called  surface  drain  is  used  in  draining  asep- 
tic wounds  for  the  purpose  of  preventing  the  accumula- 
tion of  wound  secretions  underneath  the  skin.  It  is 
made  by  twisting  a  piece  of  gutta-percha  tissue  or  pro- 
tective silk  long  enough  to  reach  beneath  the  layer  of 
adipose  tissue.  These  drains  are  placed  between  the 
sutures  and  are  generally  removed  at  the  end  of  one 
or  two  days.  All  drainage  material  is  to  be  sterilized 
by  boiling. 


Library  of 
American  Medical  AssociATioif 


CHAPTER  X. 


PREPARATION  OF  LIGATURE  AND  SUTURE  MATERIALS. 

CATGUT  AND  KANGAROO  TENDON. 

(Catgut:    Made  from  submucosa  of  the  intestine  of  sheep.) 
(Kangaroo  Tendon:     Tendonous  part  of  the  tail  of  the  kan- 
gai'oo  or  wallaby,  both  Australian  marsupial  animals.) 

The  raw  material  contains  fat  and  is  infected  with 
germs.  Both  of  these  absorbable  animal  tissues  are 
sterilized  by  the  same  processes : — 

FORMALIN  CATGUT.     (HOFMEISTER.) 

.  First. — EoU  the  catgut,  without  any  other  prepara- 
tion, in  single  layers  on  glass  tubes,  roll  tightly,  evenly, 
leaving  a  space  between  each  turn,  fasten  firmly  at 
each  end  so  that  it  will  not  loosen  during  sterilization. 

Second. —  Soak  in  sulphuric  ether  for  three  days. 

Third. — Immerse  in  solution  of  formalin,  4  per  cent., 
for  forty-eight  hours. 

Fourth. — Place  the  tubes  in  a  basin  under  running 
water  for  twelve  hours. 

Fifth. — Boil  the  catgut  on  the  tubes  in  clear  water 
from  ten  to  fifteen  minutes.  The  water  should  reach 
the  boiling  point  (212  degrees  F.)  before  the  catgut  is 
put  in. 

Preserve  in  the  following  solution: 

Alcohol    1  pint 

Glycerin     1  dram,  24  drops 

Iodoform    l'/,  ounces,  40  grains 

The  glass  jar  or  bottle  in  which  the  catgut  is  pre- 
served should  be  well  shaken  from  time  to  time,  espe- 
cially before  taking  the  catgut  out  for  use,  so  that  some 
of  the  particles  of  iodoform  may  remain  in  the  catgut. 

For  fine  and  medium  catgut  use  2  per  cent,  formalin, 
omit  the  ether  and  boil  from  seven  to  ten  minutes.   The 


FOR     THE      OPERATING      ROOM  81 

formaKn  hardens  the  catgut  and  is  also  a  powerful 
germicide.  Catgut  when  boiled  or  immersed  in  a  watery- 
solution  becomes  soft  and  unsafe  for  tying.  Therefore, 
absolute  alcohol  should  be  used.  The  glycerin  dilutes 
the  alcohol  sufficiently  and  acts  as  a  lubricant  without 
tending  to  soften  the  catgut. 

Catgut  thus  prepared  is  not  only  aseptic,  but  mildly 
antiseptic,  and  the  iodoform  does  not  irritate  the 
tissues  like  carbolic  acid  and  corrosive  sublimate. 

VON   BERGMANN'S   METHOD    OF   CATGUT  STERILI- 
ZATION. 

After  removing  the  fat  by  immersion  in  sulphuric 
ether  for  from  twenty-four  to  forty-eight  hours,  ac- 
cording to  the  size  of  the  catgut,  place  the  strands  in  a 
1  per  cent,  solution  of  corrosive  sublimate,  dissolved  in 
eighty  parts  of  alcohol  and  twenty  parts  of  water,  the 
vessel  to  be  shaken  frequently. 

AMMONIUM  SULPHATE  CATGUT.     (ELSBERG.) 

Selection  of  good  raw  material  is  necessary.  The  cat- 
gut is  wound  upon  a  square  glass  plate  with  projecting 
margins  in  order  to  expose  the  threads  fully  to  the 
boiling  solution,  as  they  touch  the  plates  only  at  four 
points. 

The  sulphate  of  ammonium  is  used  in  a  saturated 
solution.  The  boiling  is  done  in  an  enameled  vessel  and 
is  continued  for  half  an  hour,  when  the  plate  is  re- 
moved witli  a  pair  of  sterilized  forceps  and  rinsed  in 
sterilized  water.  For  a  short  time  the  catgut  is  then 
immersed  in  alcohol  to  harden  it,  when  it  is  placed  in 
sterilized  oil  of  juniper,  and  is  ready  for  use. 

Catgut  and  silk  thus  treated  are  kept  in  bottles  with 
a  wide  mouth,  securely  closed  with  a  glass  stopper, 
which  is  removed  when  the  material  is  needed,  and  a 
nickel  cover,  sterilized  by  boiling,  substituted.  Through 
a  central  perforation  the  ends  of  the  threads  are  drawn 
out. 


82  ANUESESGUIDE 

CHROMICIZED  CATGUT. 

Chromicized  catgut  is  more  durable  than  catgut  pre- 
pared in  any  other  manner.  EoU  the  catgut,  without  any 
other  preparation,  in  single  layers,  on  glass  tubes,  tight- 
ly, evenly,  leaving  a  space  between  each  turn,  and  fasten 
firmly  at  each  end  so  that  it  will  not  loosen  during 
sterilization.  Soak  in  sulphuric  ether  three  days,  then 
immerse  in  a  4  per  cent,  solution  of  formalin  for  forty- 
eight  hours.  Place  the  tubes  in  a  basin  under  running 
water  for  twelve  hours.  After  this  process  boil  the  cat- 
gut on  the  tubes  from  ten  to  fifteen  minutes. 

Immerse  in  the  following  solution  for  one  hour : 

CHROMIC  ACID  SOLUTION. 

Chromic  acid    38V2  grains 

Carbolic   acid    27  drams 

Sterilized   water    57  ounces 

Preserve  on  tubes  in  alcohol. 

IODIZED  CATGUT.      (CLAUDIUS.) 

Immerse  the  raw  coils  of  domestic  or  rough  German 
catgut,  without  any  preparation,  in  a  solution  contain- 
ing 1  per  cent,  of  pure  iodin  and  1  per  cent,  of  potassic 
iodid.  In  eight  days  the  catgut  is  absolutely  sterile. 
Claudius  preserves  the  material  in  the  same  solution, 
but  experience  has  taught  me  that  in  three  or  four 
weeks  the  catgut  becomes  too  brittle.  I  now  preserve 
it  in  a  10  per  cent,  iodoform-alcohol  mixture.  I  add 
iodoform  in  order  to  insure  free  iodinization  for  an  in- 
definite time. 

The  bottle  containing  the  catgut  should  be  freely 
shaken  every  few  days  for  the  purpose  of  bringing  the 
deposited  iodoform  in  frequent  contact  with  the  threads. 
The  iodin  solution  is  prepared  as  follows : 

Dissolve  the  potassic  iodid  in  a  small  quantity  of 
water,  to  which  the  iodin.  finely  triturated,  is  added, 
and  the  concentrated  solution  is  then  diluted  to  1  per 
cent. 

The  solution  and  catgut  are  kept  in  a  bottle  with  a 
wide  mouth  which  is  closed  with  an  accurately  fitting 


FOR     THE      OPERATING      ROOM  83 

glass  stopper.  The  date  is  written  on  the  label  of  the 
bottle.  Catgut  thus  prepared  and  kept  should  be  rinsed 
in  a  weak  solution  of  carbolic  acid  before  using.  Cat- 
gut preserved  in  iodoform-alcohol  requires  no  rinsing. 

HORSEHAIR. 

Wash  thoroughly  with  hot  water  and  potash  soap. 
Place  the  threads  in  line  and  fasten  at  one  end.  Wrap 
in  a  piece  of  gauze  (for  the  purpose  of  keeping  it  under 
the  water)  and  boil  for  ten  minutes  in  ^  per  cent,  so- 
lution of  soda  carbonate.  Change  this  solution  and  boil 
again  ten  minutes  in  clear  water. 

Preserve  in  a  solution  of  hydrarg.  bichlorid  and  alco- 
hol, 1 :1000. 

SILKWORM    GUT. 
Wrap  in  a  piece  of  gauze  and  boil  for  thirty  minuteci 
in  a  1  per  cent,  solution  of  soda  carbonate.   Preserve  in 
a  solution  of  hydrarg.  bichlorid,  1 :1000. 

BRAIDED  SILK. 

EoU  the  silk  on  glass  spools  and  boil  from  fifteen  to 
thirty  minutes  in  a  1  per  cent,  solution  of  soda  carbon- 
ate. Preserve  in  a  solution  of  hydrarg.  bichlorid  and 
alcohol,  1 :]  000. 


CHAPTER  XI. 


GENERAL  ANESTHESIA 

The  anesthesia  room  should  ahvays  be  supplied  with 
pure  ether,  chloroform,  oxA'gen  tanks,  appliances  for 
restoring  suspended  respiration,  and  antidotes  for  the 
toxic  effects  of  the  anesthetic. 

The  temperature  of  the  room  should  be  comfortable, 
and  all  noise  and  excitement  carefully  avoided. 

All  articles  required  should  be  in  readiness  before 
commencing  the  final  disinfection  of  the  field  of  operar 
tion.  One-half  hour  before  the  appointed  time  the  pa- 
tient is  conveyed  to  the  anesthesia  room. 

The  mouth  is  inspected  and  false  teeth  removed. 
The  remaining  teeth  are  brushed  with  warm  water  and 
soap,  and  the  mouth  is  then  rinsed  thoroughly  with 
clear  water  and  a  solution  of  l^oro-listerin.  (Boric 
acid,  saturated  solution,  1  ounce;  Listerin,  1  dram.) 

The  nasal  cavities  are  cleansed  with  cotton  swabs  and 
syringed  with  Thiersch's  solution. 

The  clothing  is  removed,  and  sterilized  sheets  placed 
under  and  over  the  patient.  The  head  is  covered  with 
an  aseptic  gauze  bandage,  or  an  aseptic  towel  is  wrapped 
around  and  pinned,  after  which  the  patient  is  dressed 
in  a  sterilized  surgical  suit. 

The  field  of  operation  is  then  scrubbed  with  hot  water 
ajid  potash  soap,  washed  off  with  warm  water,  and  a 
gauze  sponge  saturated  with  turpentine  is  rubbed  over 
the  surface,  which  is  again  scrubbed  with  hot  water 
and  potash  soap  and  rinsed  with  clear  water  and 
sponged  with  alcohol  and  warm  bichlorid  solution, 
1 :1000.  A  sterilized  towel  saturated  with  the  same  so- 
lution is  wrung  tightly,  folded  and  placed  over  the  dis- 
infected area  and  covered  with  a  dry  aseptic  towel. 

The  patient  is  then  catheterized  and  the  lower  limbs 


POE     THE      OPERATING      ROOM  85 

Avrapped  in  flannel  or  a  blanket  and  covered  with  a 
sterilized  sheet,  after  which  the  anesthetic  is  adminis- 
tered. 

In  the  absence  of  a  qualified  assistant,  the  educated 
nurse  is  often  called  upon  to  administer  a  general  anes- 
thetic and  should,  therefore,  be  familiar  with  the  meth- 
od and  quick  to  discover  signs  of  danger  and  prompt  in 
anticipating  them  by  judicious,  intelligent  treatment. 

In  emergency  work  anesthetics  must  often  be  given 
without  any  elaborate  preparations,  owing  to  the 
urgency  of  the  case.  When  time  permits,  everything 
should  be  done  to  make  ample  preparations  for  all  pos- 
sible emergencies.  The  stomach  should  invariably  be 
empty.  Vomiting  is  likely  to  be  provoked  by  the  anes- 
thetic and  the  food  ejected  might  enter  the  air  passages, 
causing  immediate  death  from  asphyxia,  or,  if  this  dan- 
ger is  passed  over,  an  aspiration  pneumonia  is  a  more 
remote  complication.  If  the  anesthetic  has  to  be  given 
on  a  full  stomach,  the  patient  should  be  turned  on  one 
side,  with  ijie  head  in  a  dependent  position  during  the 
s.ct  of  vomiting,  so  as  to  favor  the  ejection  of  the  food 
from  the  mouth. 

The  bowels  and  bladder  should  be  evacuated,  the 
former  by  cathartics  and  enema,  the  latter,  if  need  be, 
by  aseptic  catheterization. 

All  unnecessary  clothing  must  be  removed,  especially 
such  as  would  interfere  with  the  free  movements  of  the 
chest  and  abdomen. 

The  patient  is  placed  on  the  operating  table,  with 
the  head  on  the  same  level  as  the  body,  or  slightly  low- 
ered on  a  small  pillow,  or,  what  is  still  better,  a  firm 
compress. 

Keeping  the  head  in  a  slightly  dependent  position 
prevents  the  danger  of  aspiration  into  the  air  passages 
of  the  infected  secretions  of  the  mouth, — a  fruitful 
source  of  bronchitis  and  pneumonia, — after  the  admin- 
istration of  a  general  anesthetic. 

The  position  of  the  patient  may  have  to  be  changed 


86 


A     NURSE     S      GUIDE 


if  he  is  obese.  Kraske  and  others  have  recently  called 
attention  to  the  danger  which  attends  anesthetization 
of  obese  persons  placed  in  the  Trendelenburg  position, 
and  Trendelenburg  himself  has  cautioned  against  this 
position  in  that  class  of  patients. 

Upon  a  small  stand  or  chair  at  the  head  of  the  operat- 
ing table,  and  within  easy  reach  of  the  anesthetizer,  are 
placed  all  articles  needed  during  narcosis — ether,  chlo- 
roform, tongue-holder,  hypodermic  syringe  charged 
with  a  solution  of  1/30  of  a  grain  of  strychnin,  granules 
of  digitalin,  1/100  of  a  grain,  granules  of  atropin,  1/100 
of  a  grain,  capsules  of  nitrite  of  amyl,  wash  basin, 
tongue  forceps,  mouth  gag,  cotton  or  gauze  swabs,  a 
four-ounce  bottle  of  whisky   or   brandy,   a   two-ounce 


Luer's    Hypodermic    Syringe. 


Luer's  Hypodermic 
Syringe  Case. 


bottle  of  vinegar,  an  electric  battery,  a  chloroform 
mask,  an  ether  cone,  a  sponge  holder,  small  gauze 
sponges,  and  a  number  of  towels. 

The  anesthetic  must  be  pure — Squibb's  etlier  and 
chloroform  can  be  relied  upon. 

In  hospital  practice  the  nitrous  oxid,  or  laughing  gas, 
is  now  frequently  employed  as  a  preliminary  to  ether 
and  chloroform  anesthetization. 

Ever}'thing  being  in  readiness  for  the  narcosis,  the 
surface  of  the  body  not  to  be  exposed  during  the  operar 
tion  should  be  well  protected  with  woolen  blankets  so 
as  to  prevent  unnecessary  and  perhaps  dangerous  loss 
of  body  heat  during  the  operation. 


Proper  Position  of  Patient  and  Anestlietlzer  and  Stand  for  Anestlietic  and  Accessories. 


FOR     THE      OPERATING      ROOM  80 

The  temperature  of  the  room  should  not  be  lower 
than  75  degrees  F.  and  not  higher  than  85  degrees  F., 
according  to  the  general  condition  of  the  patient  and  the 
nature  and  probable  duration  of  the  operation. 

The  skin  exposed  to  the  irritating  action  of  the  anes- 
thetic is  covered  with  oil,  vaselin,  butter,  cream  or  any 
other  fatty  substance. 

The  anesthetizer  takes  his  place  at  the  head  of  the 
table,  seated  on  a  chair  or  stool  of  convenient  height. 

The  patient's  mind  must  be  diverted  as  much  as  pos- 
sible from  the  ordeal  before  him.  With  the  exception 
of  a  few  words  of  encouragement,  no  conversation 
should  be  carried  on  between  the  patient  and  the  anes- 
thetizer after  the  narcosis  has  commenced,  and 
strangers  and  anxious  relatives  should  be  excluded 
from  the  room.    Silence  must  be  strictly  enforced. 

A  few  drops  of  chloroform  are  poured  on  the  mask, 
or,  in  the  absence  of  such,  on  a  handkerchief  folded 
once  or  twice  and  held  for  a  few  minutes  at  least  four 
inches  from  the  face,  when  it  is  brought  gradually 
nearer,  but  not  in  contact  with  the  face,  until  the  pa- 
tient has  become  accustomed  to  the  irritating  effects  of 
the  vapor.  The  same  precaution  is  necessary  in  admin- 
istering ether.  As  soon  as  the  mask  has  been  brought 
in  contact  with  the  face  the  chloroform  is  dropped 
upon  it  continuously,  as  an  abundance  of  air  passes 
through  the  loose  meshes  of  the  gauze,  thus  diluting  the 
vapor  of  the  anesthetic  and  furnishing  the  necessary 
amount  of  oxygen. 

It  is  during  the  beginning  of  the  narcosis  that  the 
patient's  mind  should  be  occupied  and  concentrated 
upon  something  foreign  to  the  procedure  he  is  under- 
going. This  can  be  accomplished  in  one  of  two  ways: 
He  is  asked  to  count  slowly  until  consciousness  is  lost 
(counting  backward  from  one  hundred  rivets  the  atten- 
tion of  the  patient  more  tban  counting  in  the  ordinary 
way  from  one  upward),  or  is  requested  to  hold  one  of 
the  upper  extremities  in  a  vertical  position.    The  loss 


90 


A     NURSES     GUIDE 


of  consciousness  in  the  latter  instance  is  announced  by 
the  dropping  of  the  helpless  limb.  This  stage  of  anes- 
thesia will  sufiBce  for  short  operations  and  when  it  is 
intended  to  operate  under  partial  anesthesia.  Usually 
complete  anesthesia  is  preceded  by  a  stage  of  excite- 
ment of  variable  duration.  It  is  during  this  stage  that 
the  anesthetizer  feels  keenly  the  weight  of  his  responsi- 
bility. The  patient  shouts,  prays,  swears,  sings,  cries, 
laughs  or  fights,  according  to  his  temperament,  habits, 
religious  belief,  occupation  or  social  position  in  life. 
Tonic  and  clonic  spasms,  irregular  respiration  and 
cyanosis  are  some  of  the  alarming  symptoms  of  this 


A.  Seno's  Chloioform  Inhaler. 


B.  Seun's  Ether  Inhaler. 


stage.  This  stage  may  subside  in  a  few  minutes,  or  may 
continue  for  ten  or  fifteen  minutes,  or  even  for  a  longer 
time.  Under  the  continued  administration  of  chloro- 
form by  the  drop  method  the  excitement  and  convulsive 
movements  gradually  subside,  and  the  narcosis  passes 
into  the  stage  of  tolerance  or  full  anesthesia.  This  is 
announced  by  muscular  relaxation,  snoring,  puffing  of 
the  cheeks  and  complete  loss  of  consciousness  and  sensi- 
bility. The  pupil  is  contracted,  the  eyeballs  make 
asymmetric  movements,  the  pulse  becomes  smaller, 
softer  and  more  rapid,  the  respirations  become  more 
rapid  and  phallow.   This  is  as  far  as  it  is  advisable  and 


Esmarch's    Chloroform    Inhaler. 


Heister's  Gag. 


O'Neill's  Gag. 


92  A    nurse's    guide 

safe  to  carry  the  efEect  of  the  anesthetic.  The  disap- 
pearance of  the  corneal  reflex  is  an  indication  that  the 
anesthesia  has  reached  the  limits  of  safety.  Dilatation 
of  the  pupils  is  always  a  signal  of  great  danger  and  a 
strong  and  unmistakable  reminder  that  the  effect  of  the 
anesthetic  has  been  carried  beyond  the  limit  of  safety. 
The  administration  of  the  anesthetic  must  be  immedi- 
ately suspended  until  the  pupils  contract  and  the  cor- 
neal reflex  returns. 

One  of  the  common  first  ill  effects  of  the  anesthetic 
is  the  disturbance  of  the  function  of  respiration.  Dur- 
ing the  first  few  inhalations  the  patient  often  holds  his 
breath,  and  respiration  is  renewed  by  asking  the  pa- 
tient to  breathe.  In  other  cases  the  vapor  of  chloroform 
provokes  a  distressing  cough,  but  the  cough  usually 
subsides  as  the  anesthesia  proceeds.  Prolonged  expira- 
tion interrupted  by  short  inspirations  is  objectionable, 
because  it  interferes  with  the  free  entrance  of  the  vapor 
into  the  bronchial  tubes  and  consequently  retards  the 
comjjlete  anesthesia.  The  regularity  of  respiration  in 
such  cases  is  usually  restored  by  talking  to  the  patient 
or  by  a  light  blow  on  the  chest.  Should  these  fail,  raise 
the  foot-end  of  the  operating  table.  Vomiting  may  oc- 
cur during  any  of  the  stages  of  narcosis,  especially  when 
the  stomach  of  the  patient  is  not  empty.  If  vomiting 
is  provoked,  the  head  must  be  turned  to  one  side  and  on 
a  level  below  that  of  the  body  to  prevent  entrance  of 
foreign  substances  into  the  air  passages.  An  abundance 
of  mucus  and  saliva  in'  the  pharynx  often  provokes 
vomiting,  in  which  case  the  removal  of  the  irritating 
material  with  a  sponge  held  in  the  grasp  of  a  pair  of 
long  forceps  is  the  best  and  most  successful  method  of 
preventing  or  arresting  it.  After  each  attack  of  vomii>- 
ing  the  mouth  should  be  cleared  of  food,  mucus  and 
saliva  by  wiping  with  a  sponge,  towel  or  handkerchief 
before  resuming  the  inhalation  of  the  anesthetic.  If,  in 
spite  of  all  precautions,  food  should  find  its  way  into 
the  air  passages  an  immediate  tracheotomy  may  become 


Senn's   Tongue-Holding   Forceps. 


Esmarch's  Tongue-Holding   Forceps. 


C^^^ 


\^ 


-r~iHii iiiiiM 


Sim's  Sponge  Holder. 


94  A      X  U  R  S  E     S      G  U  I  D  E 

a  necessity.  A  sudden  arrest  of  respiration,  which  dur- 
ino-  the  beginning  of  the  narcosis  is  usually  overcome 
by  attracting  the  attention  of  the  patient  by  talking  to 
him,  may  become  of  the  most  serious  import  during 
the  subsequent  stages  of  the  narcosis.  After  a  few- 
stertorous  respirations  and  stormj^  convulsive  muscular 
movements,  the  rima  glottidis  is  closed  by  muscular 
spasm,  the  abdominal  vs^all  makes  a  few  inspiratory  con- 
tractions, sinks  in  and  remains  boardlike.  The  maxil- 
lary bones  remain  in  close  contact,  and  the  tongue  falls 
backward  in  such  a  way  that  the  passage  to  the  larynx 
is  narrowed  to  an  extent  incompatible  with  a  normal 
supply  of  air  to  the  respiratory  passages. 

The  superficial  veins  of  the  forehead,   temples  and 
face  become  turgid,  the  face  purple  and  the  lips  cya- 
nosed.    The  pulse,   at  first   slow,   becomes  rapid   and, 
lastly,  almost  imperceptible.    The  cause  of  approaching 
asphyxia  in  such  cases  is  spasmodic  contraction  of  the 
muscles  of  the  larj-nx  or  falling  of  the  tongue  backward. 
Prompt  action  is  necessary  to  restore  the  embarrassed 
circulation.   The  mouth  miLst  be  opened  and  the  tongue 
grasped  and  drawn  forward  with  a  tongue-holding  for- 
ceps  (Senn's),  or,  if  such  are  not  at  hand,  a  pair  of 
mouse-toothed  hemostatic  forceps  may  be  used.    Lift- 
ing of  the  lower  jaw  forward  by  making  pressure  against 
its  angles  is  another  valuable  expedient  in  clearing  the 
phar}'nx.    On  drawing  the  tongue  forward  the  air  pas- 
sage is  cleared  and  the  anesthesia  continued  with  addi- 
tional care.    If  respiration  is  not  restored  upon  the  re- 
moval of  the  mechanical  impediments,  as  is  so  often 
the  case  when  the  narcosis  is  carried  beyond  safe  limits, 
artificial  respiration  must  be  resorted  to  promptly  and 
continued  until  respiration  is  re-established  or  all  hope 
of  restoring  life  has  vanished.   While  this  is  being  done 
an  assistant  maintains  the  patency  of  the  respiratory 
tract  by  employing  a  mouth  gag  to  open  the  mouth 
and  a  tongue-holding  or  hemostatic  forceps  to  draw  the 
organ   forward.     While    artificial   respiration   is   being 


POR     THE      OPERATING     ROOM  95 

made,  the  foot  of  the  table  is  elevated  so  as  to  incline 
the  body,  with  the  head  downward,  at  an  angle  of  45  de- 
grees. The  one  who  makes  artificial  respiration  stands 
behind  the  head  of  the  patient,  grasps  both  elbows  with 
the  arms  extended  and  by  traction  brings  the  arms  to 
the  side  of  the  head  so  as  to  expand  the  chest-wall  to 
its  utmost.  Then  the  movement  is  reversed  by  bringing 
the  arms  with  the  forearms  flexed  to  the  sides  of  the 
chest,  which  is  then  forcibly  compressed  for  the  purpose 
of  forcing  out  from  the  air  passages  as  much  as  possible 
of  the  contained  air  (Sylvester's  method). 

These  movements  must  be  made  deliberately  and  not 
spasmodically.  Sylvester's  method  is  the  only  one  of 
the  many  methods  of  artificial  respiration  that  have 
been  suggested  which  is  entitled  to  confidence  in  such 
cases.  The  respiratory  movements  are  repeated  eighteen 
to  twenty  times  a  minute,  resembling  in  this  respect 
normal  respiration.  ISTothing  is  gained  by  increasing 
the  frequency.  The  success  of  artificial  respiration  de- 
pends on  the  thoroughness  with  which  every  movement 
is  made.  If  respiration  is  not  restored  promptly  there 
is  no  reason  for  despair,  as  success  has  followed  efforts 
continued  for  half  an  hour  or  more.  The  efforts  should 
be  maintained  for  at  least  half  an  hour,  unless  unmis- 
takable evidences  of  death  make  their  appearance  and 
warrant  the  suspension  of  further  attempts  at  resusci- 
tation. 

In  desperate  cases  heart  massage  as  advised  by  Konig 
will  accomplish  much  in  stimulating  the  flagging  organ 
to  renewed  action.  The  one  who  attends  to  this  part  of 
resuscitation  stands  on  the  left  of  the  patient  and  makes 
compression  with  the  ball  of  the  right  thumb  between 
the  apex  beat  and  the  left  margin  of  the  sternum.  The 
compression  should  be  firm  and  rhythmic  at  the  rate  of 
120  a  minute,  and  should  be  continued  until  return  of 
the  pulsation  in  the  carotid  artery  is  noticeable  and  the 
pupils  contract,  or  until  such  efforts  have  shown  them- 
selves fruitless. 


Sylvester's  Method  of  Performing  Artificial  Respiration. 


Sylvester's  Method  of  Performing  Artificial  Respiration. 


EOR     THE     OPERATING     ROOM  97 

During  the  time  attempts  are  being  made  to  restore 
respiration  other  means  of  counteracting  the  toxic  ef- 
fects of  chloroform  are  employed.  The  most  potent 
physiologic  antidote  for  chloroform  is  strychnin.  Hora- 
tio C.  Wood  advises  heroic  doses.  In  adults  the  first 
dose  should  not  be  less  than  one-sixth  of  a  grain  by 
subcutaneous  injection.  This  may  be  safely  repeated 
in  ten  or  fifteen  minutes  if  the  nervous  centers  do  not 
respond  to  the  first  dose. 

Inhalations  of  nitrite  of  amyl  stimulate  the  heart's 
action  and  are  well  calculated  to  relieve  the  stagnant 
capillary  circulation.  Slapping  the  chest  with  a  towel 
wrung  out  of  cold  or  hot  water  and  the  rubbing  of  the 
extremities  are  valuable  agents  in  accomplishing  the 
same  object.  Faradization  of  the  phrenic  nerve  is  an- 
other valuable  resource  in  restoring  respiration  tem- 
porarily suspended  by  the  toxic  action  of  chloroform  on 
the  respiratory  center.  The  two  electrodes  are  applied: 
one  on  each  side  of  the  neck  over  the  clavicle  at  the 
outer  border  of  the  sterno-cleido-mastoid  muscle.  Al- 
though the  immediate  cause  of  death  from  chloroform 
is  generally  its  toxic  action  on  the  center  of  respiration, 
alarming  and  fatal  complications  may  set  in  which  are 
directly  referable  to  its  depressing  effect  on  the  heart 
muscle.  Such  accidents  usually  occur  when  least  ex- 
pected and  with  a  suddenness  that  is  appalling.  In  a 
moment  the  color  of  the  face  is  changed  to  a  deadly 
pallor;  the  pupils  dilate  and  do  not  respond  to  light; 
the  corneal  reflex  disappears;  the  lower  jaw  drops 
cadaver-like;  the  pulse  is  either  very  small,  rapid  and 
flickering  or  imperceptible";  the  heart  sounds  are  in- 
audible; bleeding  of  the  wound  ceases;  respiration,  al- 
though shallow  and  irregular,  may  continue  for  a  short 
time  until  it  ceases  after  a  few  spasmodic  efforts  similar 
to  those  observed  in  a  dying  person.  Such  a  terrible 
scene  is  fortunately  rare,  and  when  it  does  occur  it  is 
most  frequently  met  in  anemic  patients  and  in  those 
the  subjects  of  organic  disease  of  the  heart.  Nevertheless 


98  A      nurse's      GUIDE 

it  ma}'  occur  in  persons  in  perfect  health,  more  especially 
if  they  are  apprehensive,  nervous  and  excited  before 
the  operation.  Prompt  action  is  urgently  indicated 
in  all  cases  of  anesthesia  in  which  heart  depression 
follows  as  one  of  the  toxic  effects  of  the  anesthetic. 
Inversion  of  the  body  is  the  first  measure  to  be  em- 
ployed in  such  cases.  To  accomplish  this  in  the  shortest 
space  of  time  the  foot-end  of  the  operating  table  is  ele- 
vated to  an  angle  of  at  least  45  degrees.  This  position 
relieves  the  existing  cerebral  anemia,  and  by  doing  so 
the  heart  center  and  the  heart  likewise  are  stimulated 
by  the  increased  supply  of  blood.  The  patient  is  at  the 
same  time  placed  most  favorably  for  artificial  respira- 
tion, which  becomes  necessary  if  there  is,  as  is  often  the 
case,  at  the  same  time  an  inhibition  of  the  respiratory 
function.  Heart  stimulant?  by  hypodermic  injection 
are  always  indicated.  Of  these  digitalis  or  digitalin, 
strychnin,  alcohol  and  coffee  will  prove  most  effectual. 
Tincture  of  digitalis  or  digitalin,  the  former  in  half- 
dram  doses,  the  latter  in  doses  of  from  1/100  to  1/50 
of  a  grain  every  ten  to  fifteen  minutes  until  reaction 
takes  place,  will  prove  most  successful.  In  very  grave 
cases  it  should  be  combined  with  strychnin  in  decided 
doses.  Camphorated  oil  administered  in  the  same  way, 
in  doses  of  two  or  three  s^^ingefuls,  is  a  very  powerful 
cardiac  stimulant  entitled  to  confidence  in  such  cases. 
Alcohol,  in  the  form  of  whisky,  brandy,  co.srnac  or  rum, 
can  be  given  at  short  intervals  by  subcutaneous  injec- 
tions or  by  the  rectum.  The  application  of  dry  heat  to 
the  extremities  and  trunk  should  never  be  neglected. 
Friction  with  hot  cloths  is  a  potent  vascular  stimulant 
and  will  be  useful  in  aiding  the  other  remedies  in  re- 
storing the  general  circulation. 

The  physiologic  effect  of  ether  is  closely  allied  to 
that  of  chloroform,  differing,  however,  from  the  latter 
in  that  the  intracranial  blood  supply  is  rather  increased 
than  diminished  imder  full  anesthesia,  and  it  is,  there- 
fore, less  likely  to  cause  depression  of  the  heart's  ac- 


FOR     THE      OPEEATING     ROOM  99 

tion.  The  ultimate  toxic  effects  on  the  brain  and  spinal 
cord  are  almost  identical  with  those  of  chloroform,  and 
hence  its  use  demands  the  same  preliminary  prepara- 
tions and  precautions  during  its  administration.  The 
cone  must  be  held  at  first  at  least  six  inches  from  the 
face,  and  as  the  patient  becomes  accustomed  to  the 
penetrating  odor  of  the  vapor  it  is  brought  slowly  nearer 
until  it  rests  evenly  on  the  surface  and  close  enough  to 
prevent  the  entrance  of  air  underneath  it. 

It  must  not  be  forgotten  that  ether  is  a  highly  in- 
flammable substance,  and  on  this  account  special  care 
must  be  exercised  in  its  use  in  operations  where  the  aid 
of  lamp  light  is  necessary  and  in  the  use  of  the  Pac- 
quelin  cautery  near  the  ether  cone.  Accidents  during 
ether  narcosis  are  met  by  the  same  treatment  as  has  been 
described  under  the  head  of  chloroform  anesthesia. 

The  subject  of  "General  Anesthesia'^  may  be  sum- 
marized briefly  as  follows:  Proper  preparation  of  the 
patient;  adequate  supply  of  the  different  antidotes  and 
means  of  restoring  suspended  respiration;  pure  anes- 
thetics and  slow,  continuous  inhalation;  dilution  of 
the  vapor  with  a  liberal  supply  of  air;  unremitting  vig- 
ilance ajid  prompt,  efficient  and  persistent  treatment 
when  unfavorable  or  alarming  symptoms  make  it  neces- 
sary to  interrupt  the  anesthesia. 

LOCAL  ANESTHESIA. 

Local  anesthesia  is  the  ideal  condition  under  which 
to  operate,  as  it  relieves  the  operator  from  all  anxiety 
regarding  the  dangers  incident  to  the  administration  of 
a  general  anesthetic.  Ice  applied  for  a  sufficient  length 
of  time  produces  a  decided  local  anesthetic  effect  which 
includes  the  whole  thickness  of  the  skin.  The  degree  of 
cold  is  increased  and  its  anesthetic  properties  intensified 
by  mixing  common  salt  with  crushed  ice.  The  ice  and 
salt  should  be  well  mixed  and  applied  in  a  gauze  bag  or 
in  a  towel.  As  soon  as  the  skin  is  whitened  by  the  cold 
an  incision  can  be  made  through  it  with  little  or  no 


100  A    nurse's    guide 

pain.  This  is  one  of  the  simplest  and  at  the  same  time 
most  efficient  procedures  for  preventing  pain  in  excising 
small  tumors  of  the  skin  and  incising  superficial  ab- 
scesses. 

Sulphuric  ether  is  also  used  in  the  form  of  a  spray. 
An  ordinary  hand  spray  answers  an  excellent  purpose. 
Under  the  action  of  the  spray  the  skin  is  partly  frozen 
in  a  very  few  seconds,  and  a  small  incision  can  be  made 
without  any  pain. 

The  anesthetic  area  in  this  method  of  local  anesthesia 
is  small,  as  the  spray  must  be  concentrated  for  the  pur- 
pose of  producing  the  anesthetic  degree  of  cold.  During 
the  local  reaction  from  the  freezing  process  the  patient 
experiences  a  prickling  pain  in  the  part,  which  can  be 
relieved  to  some  degree  by  immersion  in  warm  water. 

More  effective  than  ether  are  the  chlorids  of  methyl 
and  ethyl.  The  first  is  applied  to  the  skin  in  a  compress 


Small  Glass  Tube  of  Chlorid  of  Ethyl. 

saturated  with  it,  and  held  against  the  part  to  be 
frozen.  The  area  of  anesthetization  is  regulated  in  this 
instance  by  the  size  of  the  compress,  possessing  in  this 
respect  a  decided  advantage  over  the  ether  and  chlorid 
ethyl  spray.  Chlorid  of  ethyl  is  so  volatile  that  it  boils 
at  the  temperature  of  the  body. 

For  local  anesthesia  it  is  put  up  in  glass  tubes  with  a 
neck  supplied  with  a  metallic  attachment  from  which 
the  spray  escapes  under  body  temperature  on  removing 
the  metallic  cork.  In  using  the  spray  the  tube  is  held 
for  a  few  moments  in  the  hollow  of  the  hand  when  the 
cork  is  removed  and  the  spray  begins. 

The  indications  for  the  use  of  the  chlorid  ethyl  spray 
are  the  same  as  for  the  ether  spray. 

Cocain  is  one  of  the  latest  and  most  useful  of  local 
anesthetics.    Applied  to  mucous  surfaces  in  solution  of 


FOR     THE     OPERATING     ROOM 


101 


from  2  to  10  per  cent.,  it  produces  a  complete  superfi- 
cial anesthesia  in  from  three  to  five  minutes.  It  is  used 
largely  in  ophthalmic  surgery  and  operations  upon 
mucous  membranes.  The  surface  must  be  carefully 
cleansed  before  the  solution  is  applied.  It  has  no  effect 
upon  intact  skin.  To  procure  anesthesia  of  the  skin  it  is 
necessary  to  inject  the  solution  into  it,  and  not  under  it. 


Lewis's    Needles    and    Syringe    for    Infiltration    Anestliesia. 

If  a  certain  area  of  skin  is  to  be  anesthetized,  the  in- 
jections are  to  be  made  with  a  hypodermic  syringe  with 
a  fine  point  under  the  strictest  aseptic  precautions,  us- 
ing in  preference  a  fresh  solution,  the  asepticity  of 
which  can  be  depended  upon.  The  needle  point  is  en- 
tered obliquely,  and  enough  fluid  is  injected  to  raise  a 
circular  portion  of  the  skin,  which  then  resembles  a 
blister. 


Sliowing  Mode  of  Injecting    Fluid  Under  an  Abscess. 

Tension  is  an  important  element  in  the  anesthetiza- 
tion of  the  skin,  as  well  as  the  local  anemia  produced  by 
it.  These  punctures  are  made  in  a  straight  line  if  the 
incision  is  to  be  made  in  this  direction,  circular  or  oval, 
according  to  the  nature  of  the  operation,  and  sufficiently 
close  together  so  that  the  different  centers  of  local  anes- 


102  A      X  U  K  S  E  '  S      GUIDE 

tliesia  touch  each  other.  xA.fter  the  first  puncture  i< 
made,  the  needle  is  always  inserted  through  the  skin 
already  anesthetized. 

Cocain  is  not  an  indifferent  drug.  Many  cases  of  se- 
vere intoxication  and  a  few  deaths  from  its  use  have 
been  reported.  The  toxic  effects  of  cocain  are  mani- 
fested by  pallor,  dizziness,  fainting,  headache  and  de- 
lirium, symptoms  which  demand  immediate  suspension 
of  its  further  use.  To  relieve  this  condition  nitrite  of 
amyl  must  be  administered  by  inhalation,  to  be  followed 
if  the  patient  does  not  rally  promptly,  by  subcutaneous 
injection  of  strychnin,  and  alcohol  by  mouth  or  rectum. 

For  subcutaneous  use  the  cocain  solution  has  l)een 
displaced  almost  entirely  by  Schleich's  infiltration 
method.  This  method  consists  in  the  use  of  cocain  and 
morphin  in  small  doses  in  normal  salt  solution  suffi- 
cient in  amount  to  produce  the  necessary  degree  of  ten- 
sion and  local  anemia.  Schleich  recommends  the  fol- 
lowing solutions,  which  are  known  as  ISTos.  1,  2  and  3, 
according  to  their  strength : 

schleich's  solution,   no.  1_.  strong. 

Cocain  muriate 0.2  gm.    (3  gr.) 

Morphin  muriate 0.025  gm.    (2/5  gr.) 

Sodium   chlorid    0.2  gm.  (3  gr.) 

Sterilized  water 100  c.c.    (3  2/5  fl.  oz.) 

NO.    2,    NORjrAL. 

Cocain  muriate 0.1  gm.   (1%  gr.) 

Morphin  muriate    0.025  gm.  (2/5  gr.) 

Sodium  chlorid 0.2  gm.    (3  gr.) 

Sterilized   water    100  c.c.  (3  2/5  fl.  oz.) 

NO.    3,    WEAK. 

Cocain  muriate 0.01  gm.    (1/6  gr.) 

Morphin  muriate 0.025  gm.    (2/5  gr.) 

Sodium  chlorid 0.2  gm.   (3  gr.) 

Sterilized   water    100  c.c.  (3  2/5  fl.  oz.) 

To  each  of  the  solutions  two  drops  of  a  5  per  cent. 
solution  of  carbolic  acid  may  be  added  if  they  are  in- 
tended for  stock  solutions  to  preserve  them  in  a  more 
nearly  aseptic  state. 


FOE      THE      OPERATING      EOOM  103 

Of  the  No,  1  solution,  as  much  as  6.5  fluid  drams 
may  be  injected  during  one  operation;  of  the  No.  2,  as 
much  as  3.4  fluid  ounces,  and  of  the  No.  3,  even  a  pint 
has  been  used  with  safety.  The  No.  2  solution  is  the 
one  generally  used,  the  strong  and  weak  solutions  being 
applicable  only  in  exceptional  cases.  In  infants  and 
children,  a  general  anesthetic  is  preferable  to  local  in- 
filtration by  Schleich's  method.  No.  1,  the  strong  solu- 
tion, is  seldom  used. 

Beta-eucain  is  now  frequently  used  as  a  substitute  for 
cocain,  as  it  is  less  toxic  and  produces  the  same  anes- 
thetic effects.  A  3  per  cent,  solution  of  this  local  anes- 
thetic injected  along  the  line  of  incision  produces  com- 
plete local  anesthesia.  A  syringeful  of  a  2  per  cent, 
solution  (twenty  minims)  is  injected  into  the  subcu- 
taneous tissues  in  three  or  four  places  and  the  syringe 
is  again  filled  and  used  to  moisten  the  wound,  or  inject 
if  necessary,  forty  minims  in  all.  The  anesthesia  thus 
produced  lasts  for  half  an  hour. 

Tropo-cocain  is  less  irritating  and  toxic  than  cocain 
and  consequently  has  been  used  quite  extensively  as  a 
substitute  for  the  latter  drug  as  a  local  anesthetic  by 
the  infiltration  method.  The  dose  should  not  exceed 
from  %  to  1%  grains. 

SPINAL  ANESTHESIA. 

Local  anesthesia  on  a  large  scale  has  been  practiced 
by  injecting  cocain  or  beta-eucain  solution  into  the 
spinal  canal.  The  injection  is  made  with  a  hypodermic 
needle.  The  parts  below  the  seat  of  injection  are  there- 
by rendered  anesthetic. 

This  practice  was  first  suggested  by  Corning  and  was 
revived  and  perfected  by  Bier.  A  large  clinical  experi- 
ence has  sufficed  to  render  it  almost  obsolete  at  the 
present  time. 


CHAPTER  XII. 


PREPARATION   OF   PATIENT  FOR   LAPAROTOMY. 

Except  in  emergency  cases  the  preparatory  treatment 
should  be  commenced  three  days  before  operation^  dur- 
ing which  time  the  patient  is  strictly  confined  to  light, 
though  nutritious,  diet,  and  receives  each  day  a  warm 
bath,  laxative,  and,  in  operations  on  uterus  or  vagina, 
vaginal  douche.  To  patients  who  have  stricture  of  the 
esophagus,  pylorus  or  intestine  no  cathartic  is  given, 
but,  with  the  doctor's  permission,  give  a  high  enema. 
For  pyloric  or  intestinal  obstruction  wash  out  the 
stomach  (gastric  lavage). 

On  the  evening  before  the  operation  and  previous  to 
shaving  the  abdomen  denude  the  pubes  with  scissors 
and  apply  a  potash  soap  poultice.  After  an  hour  re- 
move the  poultice  and  shave  the  entire  abdomen,  pubes 
and  genitalia,  scrub  with  hot  water  and  potash  soap; 
wrap  a  little  cotton  on  the  end  of  a  match  or  probe  to 
clean  the  umbilicus.  Wash  off  with  sterile  water  and 
scrub  again,  using  turpentine  and  soap;  rinse  with 
warm  water  and  dry  with  gauze; 'rub  ether  well  into  the 
skin,  sponge  Avith  alcohol,  then  use  warm  bichlorid  solu- 
tion, 1 :1000,  and  cover  the  field  of  operation  with  a 
three-yard  compress  of  sterile  gauze,  saturated  with 
warm  solution  of  bichlorid,  strength  1 :3000  or  1 :5000, 
oiled  muslin  or  waxed  paper,  pad  of  cotton  and  inclose 
all  in  a  snug  abdominal  bandage,  held  in  place  by  per- 
ineal straps. 

For  abdominal  and  vaginal  hysterectomy,  also  for 
operations  on  cervix,  the  vagina  should  be  disinfected 
in  the  following  manner:  Wrap  gauze  around  the  in- 
dex finger,  and  mop  with  hot  water  and  soap;  then  use 
clear  water,  give  a  douche  of  bichlorid  1 :4000  and  pack 
cervix  with  a  strip  of  iodoform  gauze.    One  hour  before 


FOR      THE      OPERATING      ROOM  105 

the  operation  remove  the  gauze  and  give  corrosive  .sub- 
limate douche  and  mop  vagina  thoroughly  with  alcohol 
before  repacking. 

Each  of  the  following  articles  should  be  in  readiness 
before  commencing  to  prepare  the  patient :  One  pitcher 
of  hot  water,  bottle  of  warm  bichlorid,  two  basins,  small 
bottle  of  turpentine,  ether  and  alcohol,  brush,  potash 
soap,  razor,  probe  tipped  with  cotton,  several  pieces  of 
gauze,  oiled  muslin,  gutta-percha  tissue  or  waxed  paper, 
cotton  pad,  abdominal  binder,  perineal  straps,  eight 
safety  pins  and  a  pair  of  scissors. 

The  patient  receives  a  very  light  supper  and  no  break- 
fast. One-half  ounce  of  brandy  diluted  with  water  may 
be  given  four  hours  previous  to  the  operation. 

A  specimen  of  urine  should  be  placed  in  a  sterile  bot- 
tle for  examination. 

Five  hours  before  the  operation  give  a  high  enema  of 
castile  soap  suds,  followed  by  a  small  one  of  clear  water 
to  rinse  the  bowel. 

Before  leaving  the  room  the  patient  is  attired  in  clean 
clothing,  including  a  pair  of  stockings;  the  hair  plaited 
tightly  in  two  braids. 

After  patient  is  placed  on  the  operating  table  the 
head-nurse  applies  laparotomy  sheet  and  surrounds 
field  of  operation  with  dry  sterilized  towels.  The  opera- 
tor and  his  assistants,  having  completed  the  thorough 
disinfection  of  hands,  are  dressed  in  sterilized  operat- 
ing gowns  and  caps  or  sterile  towels  are  pinned  around 
each  one's  head.  The  head-nurse  takes  charge  of  the 
instruments,  ligatures  and  sutures.  Immediately  before 
the  incision  is  made  she  pours  alcohol  upon  the  hands 
of  the  operator  and  his  assistants.  She  is  then  pre- 
pared to  anticipate  every  want  of  the  surgeon,  begin- 
ning with  the  scalpel,  following  with  forceps,  scissors, 
etc.,  as  may  be  required.  Having  provided  a  separate 
tray,  she  brushes  the  soiled  instruments  when  necessary, 
and  takes  each  needle  from  the  surgeon  when  he  has 


106  A    nuese's    guide 

finished  with  it,  for,  if  left  lying  about,  serious  injujy 
to  the  patient  may  result. 

The  senior  nurse  takes  charge  of  the  sponges  and 
laparotomy  compresses.  She  stands  conveniently  near 
the  assistant  who  is  to  do  the  sponging;  if  asked  to  do 
the  sponging,  she  does  not  wipe,  but  merely  compresses 
the  bleeding  parts,  allowing  the  sponge  to  absorb  what 
it  will.  After  the  peritoneum  is  opened,  she  hands  the 
small  sponges  on  a  hemostatic  forceps;  this  is  called 
"steel-sponge."  The  laparotomy  compresses  will  then 
be  needed.  These,  before  being  handed  to  the  surgeon, 
are  wrung  out  of  a  hot  solution  of  sodium  chlorid, 
6/10  of  1  per  cent,  (about  1  dram  of  salt  to  1  quart  of 
water,  called  physiologic  solution).  A  hemostatic  for- 
ceps is  attached  to  the  tape,  Which  is  securely  fastened 
to  an  end  of  each  of  the  compresses.  The  nurse,  being 
accountable  for  compresses,  keeps  a  record  of  them,  and 
before  the  incision  is  closed  she  counts  them  again  to 
make  sure  that  none  is  left  in  the  abdomen. 

Upon  the  junior  nurse  devolves  the  care  of  the  doc- 
tors' hands  and  brows.  If  anything  not  aseptic  has 
been  touched  by  them,  she  hands  bichlorid  solution,  or, 
when  only  blood  is  to  be  removed,  a  basin  of  warm 
physiologic  solution  suffices. 

For  a  laparotomy  the  temperature  of  the  operating 
room  should  be  75  to  80  degrees  F.  Consequently  the  doc- 
tors will  perspire  profusely;  a  few  drops  of  perspiration 
falling  into  the  open  wound  might  cause  sepsis;  there- 
fore, to  avoid  this  danger,  the  nurse  must  wipe  the  doc- 
tors' brows.  This  nurse  must  be  on  the  alert  to  notice 
and  supply  every  want,  if  so  directed  by  the  head-nurse. 

One  of  the  highest  qualifications  of  a  good  nurse  in 
the  operating  room  is  to  anticipate  the  wants  of  the 
surgeon. 


CHAPTER  XIII. 


AFTER-TREATMENT  FOR  LAPAROTOMY  PATIENTS. 

In  the  treatment  after  a  laparotomy,  the  nurse  should 
carefully  observe  the  condition  of  the  patient,  and  give 
timely  information  of  the  onset  of  serious  complica- 
tions, the  most  important  of  which  are  shock,  secondary 
hemorrhage  and  peritonitis. 

The  patient  is  carefully  conveyed  without  raising 
head  or  chest  to  the  bed,  which  has  been  previously  pre- 
pared with  a  rubber  and  a  draw  sheet,  well  supplied 
with  hot-water  bags  or  bottles,  for  armpits  and  lower 
extremities.  Cover  the  hot-water  bags  and  bottles  that 
they  may  not  bum  the  insensible  patient.  (Much  harm 
has  been  done  by  not  observing  this  precaution,  and  a 
number  of  suits  for  damages  have  been  based  upon  care- 
lessness or  negligence  in  this  respect.)  The  patient  is 
placed  in  the  dorsal  (recumbent)  position  with  the 
limbs  flexed  to  relax  the  abdominal  muscles,  and  a  pil- 
low placed  under  the  knees  to  support  them.  This  po- 
sition is  retained  for  forty-eight  hours,  during  which 
time  the  patient  is  constantly  watched.  At  the  termi- 
nation of  this  period  the  patient  may  be  carefully  turned 
on  either  side.  Pulse  and  temperature  should  be  taken 
immediately  after  every  operation;  temperature  should 
be  taken  by  rectum.  (Never  take  aged  persons'  tem- 
perature in  the  axilla.) 

Hjrpodermatic  syringe,  brandy,  strychnin,  nitrogly- 
cerin, digitalis,  flannel  bandages  and  blocks  to  elevate 
the  foot  of  the  bed  should  be  kept  in  readiness. 

All  articles  and  medicines  necessary  in  the  after- 
treatment  should  be  arranged  on  a  table  in  the  patient's 
room  before  the  return  of  the  patient  from  the  operat- 
ing room. 

The  distressing  thirst  is  relieved  by  sips  of  hot  water 


110  A      XURSE''S      GUIDE 

given  at  short  intervals  or  by  fragments  of  cracked  ice. 
^0  food  by  mouth  should  be  given  during  the  first  for- 
ty-eight hours.  In  cases  of  persistent  vomiting  stimu- 
lants and  food  are  administered  by  rectum. 

A  beginning  t^mipanitis  calls  for  an  effective  enema. 
Of  the  different  enemata  employed  under  such  circum- 
stances, none  acts  more  promptly  than  one  consisting  of 
a  pint  of  milk  and  an  equal  amount  of  molasses,  which 
should  be  thoroughly  mixed  and  heated  to  the  usual  de- 
gree of  temperature  (about  100  degrees  F.). 

DIET. 

After  a  laparotomy  the  patient  receives  nothing  in 
the  form  of  nourishment  by  mouth  for  at  least  thirty- 
six  hours.  The  mouth  should  be  frequently  sponged 
and  the  lips  moistened.  A  piece  of  ice  wrapped  in  gauze 
and  rubbed  over  the  lips  is  very  soothing  to  the  patient, 
and  in  cases  of  extreme  thirst  very  hot  water  may  be 
given  in  one-half  ounce  doses,  but  as  seldom  as  possible. 
Small  pieces  of  ice  in  the  form  of  ice  pills  are  some- 
times allowed.  Hot  water,  being  a  stimulant,  is  pre- 
ferred to  ice,  which  is  a  sedative.  Another  objection  is 
the  germs  which  it  contains;  however,  the  following  is 
a  point  in  favor  of  ice — nervous  vomiting  may  be  con- 
trolled by  rubbing  it  over  the  lips.  The  best  method  in 
such  cases  is  to  give  nothing  by  mouth,  but  to  relieve 
thirst  by  rectal  or  subcutaneous  injections  of  physiologic 
solution,  thus  securing  for  the  stomach  complete  rest. 
When  giving  food  or  medicine  by  mouth  assist  the  pa- 
tient as  much  as  possible.  Fluids  should  be  adminis- 
tered by  the  use  of  curved  glass  tubes  or  feeders ;  if  ex- 
tremely weak,  nutritive  enemata  are  prescribed. 

In  the  absence  of  all  bad  symptoms,  toward  the  end 
of  the  second  day,  the  patient  may  have  a  little  pepton- 
ized milk,  beef  essence,  chicken  broth  or  kumyss,  vary- 
ing in  amount  from  one-half  ounce  to  four  ounces,  ac- 
cording to  the  condition  of  the  patient,  increasing  the 
quantity  gradually.     The  majority  of  laparotomy  cases 


FOR      THE      OPERATING      ROOM  111 

require  a  cathartic  as  soon  as  they  recover  from  the  ef- 
fects of  the  operation.  A  teaspoonful  of  sulphate  of 
magnesia  dissolved  in  hot  water  and  given  every  hour 
until  the  bowels  move  freely,  is  the  best  course  to  pur- 
sue in  relieving  the  patient  and  in  guarding  against 
peritonitis.  If  the  patient  is  vomiting  and  unable  to 
take  a  cathartic  and  not  relieved  by  the  milk  and  mo- 
lasses enema,  give  a  high  enema  of  magnesia  sulphate, 
ounces  two ;  glycerin,  ounces  four ;  and  water,  one  pint ; 
use  the  rectal  tube. 

A  hot-water  bag  applied  over  the  bladder  often  pre- 
vents the  retention  of  urine;  if  obliged  to  catheterize, 
which  should  not  be  done  under  eight  hours  after  op- 
eration, use  a  soft  rubber  catheter  (Nelaton)  ;  see  that 
it  has  been  boiled  and  afterwards  kept  aseptic. 

WOUND   COMPLICATIONS— SHOCK,   HEMORRHAGE,   ETC. 

Surgical  Slioclc. — This  may  result  either  from  injury 
or  operation.  It  is  characterized  by  its  sudden  onset 
and  great  prostration. 

Symptoms. — Almost  imperceptible  pulse,  subnormal 
temperature,  feeble  and  often  irregular  and  sighing  res- 
piration, countenance  pale  and  body  cold  to  the  touch. 

Treatment. — Elevate  the  foot  of  the  bed  (by  force  of 
gravity,  the  blood  will  flow  toward  the  head)  ;  surround 
the  patient  with  hot-water  bags;  give  brandy  hypoder- 
matically  and  give  strychnin,  grain  1/30 ;  repeat  in 
three  hours  if  necessary;  atropin,  grain  1/60,  for  the 
respiration. 

Ether  administered  subcutaneously  is  also  a  prompt 
heart  stimulant.  Caffein  or  strong  black  coffee  is  a 
simple  and  excellent  heart  stimulant.  Saline  infusion 
subcutaneously,  intravenous  or  by  rectum,  is  frequently 
called  for  in  such  cases.  With  the  doctor's  permission 
have  the  patient  inhale  amyl  nitrite;  nitroglycerin  may 
also  be  given.  Camphorated  oil  given  hypodermatically 
is  a  favorite  stimulant,  and  should  always  be  kept  in 
readiness. 


112  A    nurse's     guide 

Internal  and  secondary  hemorrhages  often  simulate 
shock  very  closely^  but  the  symptoms  appear  gradually 
and  corresiX)nd  in  severity  with  the  amount  of  blood  lost. 

The  most  prominent  symptoms  are:  Dilated  pupils, 
extreme  pallor  of  face,  subnormal  temperature,  wiry, 
rapid  pulse,  frequent  yawning,  cold  perspiration,  ex- 
treme thirst  followed  in  grave  cases  by  convulsions  and 
death. 

Notify  the  doctor  at  once.  Keep  the  patient  quiet; 
give  no  stimulants,  as  they  would  increase  the  heart's 
action  and  thereby  aggravate  the  hemorrhage;  apply 
external  heat.  While  waiting  for  the  doctor,  prepare 
physiologic  solution,  four-ounce  rectal  injecting  syringe. 
flannel  bandages  and  the  following 

Brandy. 

Strychnin. 

Digitalin  tablets. 

Nitroglycerin  tablets. 

Tincture  of  digitalis. 

Hypodermatic  syringe. 

Amyl  nitrite  pearls,  and  napkin  in  which  to  crush 
and  apply. 

Electro-magnetic  battery,  with  glass  of  water  to 
moisten  electrodes. 

The  doctor,  after  arresting  the  hemorrhage,  may  re- 
sort to  intravenous  infusion,  or  may  order  four  to  six- 
teen ounces  of  physiologic  solution  given  by  rectum. 

If  the  patient  is  sinking  rapidly,  the  nurse  is  allowed 
to  make  an  to  transfusion,  by  elevating  the  foot  of  the 
bed  and  by  elastic  compression  or  constriction,  but  only 
one  limb  at  a  time,  taking  care  that  the  constriction 
never  be  continued  for  more  than  two  hours  at  a  time. 

PERITONITIS. 

(Inflammation  of  the  peritoneum,  which  is  the  serous 
membrane  lining  the  abdomen.) 

This  is  the  next  danger  to  be  apprehended  after  lap- 
arotomy. 

Symptoms. — High    temperature,    quick,    wiry    pulse, 


FOE      THE      OPERATING      ROOM  113 

vomiting,  distended  abdomen  and  severe,  continuous 
pains. 

In  the  most  serious  forms  of  septic  peritonitis  the 
temperature  is  sometimes  subnormal,  pain  absent  as  well 
as  tympanites,  but  the  pulse  and  dry  tongue  indicate 
the  existence  of  progressive  sepsis. 

The  milk-molasses,  or  a  four-ounce  enema  of  glycerin 
and  water,  equal  parts,  will  sometimes  relieve  tympan- 
itic pains  immediately.  However,  the  patient  should 
have  free  defecation  at  once.  G-ive  a  saline  cathartic: 
the  action  of  saline  cathartics  can  be  hastened  by  the 
administration  of  a  turpentine  enema  (one-half  ounce 
of  turpentine;  two  ounces  of  castor  oil  to  one  quart 
of  soap  suds).  A  brisk  saline  cathartic  promotes  ab- 
sorption of  fluids  and  bacteria  from  the  peritoneal  cav- 
ity, and  by  so  doing  removes  the  essential  cause  of  peri- 
tonitis. 

Patients  with  tympanites  should  have  the  abdomen 
examined  frequently  for  the  first  forty-eight  hours. 

One  exception  to  the  rule  of  giving  a  cathartic  is 
when  the  operation  is  performed  on  the  intestine  and  in 
the  formation  of  an  artificial  anus.  In  the  latter  case 
the  bowel  is  kept  at  rest  until  it  is  incised,  which  is 
usually  done  on  the  second  or  third  day  after  the  oper- 
ation. 

In  cases  of  beginning  peritonitis  and  intestinal  ob- 
struction, the  nurse  is,  if  requested,  to  administer  a 
high  rectal  enema,  for  which  she  should  prepare  one 
gallon  of  soapsuds,  adding  four  ounces  of  sulphate  of 
magnesia;  four  ounces  of  castor  oil  and  two  ounces  of 
turpentine;  mix  well.  Place  the  patient  on  the  right 
side;  elevate  the  foot  of  the  bed  three  feet,  raise  the 
irrigator  five  feet  above  the  level  of  the  patient;  insert 
the  rectal  tube. 

In  the  case  of  an  adult,  administer  the  whole  gallon, 
which  will  take  from  one-half  to  one  hour;  assist  the 
patient  to  retain  the  solution  as  long  as  possible,  by 
compressing  the  anus  with  a  towel,  after  which,  to  fa- 


114  A      NURSE^S       GUIDE 

cilitate  evacuation,  lower  the  foot  of  the  bed,  and  elevate 
the  head  of  the  bed  at  least  two  feet. 

SEPTICEMIA. 

(A  general  infective  process  from  absorption  of  septic  pro- 
ducts usually  the  result  of  infection  with  pus  microbes.) 

Septicemia  usually  begins  with  a  chill  or  sense  of 
chilliness,  followed  by  a  gradual  rise  of  temperature. 
The  pulse  is  rapid,  feeble  and  compressible.  The  tongue 
is  usually  furred  and  dry.  Headache  is  often  com- 
plained of  in  the  beginning  of  the  attack.  The  urine 
is  scanty  and  heavily  loaded  with  urates.  Delirium, 
restlessness  and  insomnia  are  symptoms  which  denote 
approaching  danger. 

The  debilitating  effect  of  toxins  on  the  heart  are  met 
by  the  timely  and  judicious  administration  of  stimu- 
lants, during  which  the  condition  of  the  pulse  should 
be  frequently  noted. 

Treatment. — Alcoholic  stimulants  are  to  be  given 
in  doses  sufficiently  large  to  improve  the  character  of 
the  pulse  and  at  sufficiently  short  intervals  to  maintain 
this  effect  without  interruption.  Brandy  or  whisky  in 
doses  of  an  ounce  every  two  hours  diluted  with  water 
is  most  to  be  relied  -apon,  but  champagne  and  Greek 
sherry  are  excellent  substitutes.  Concentrated  liquid 
food,  like  beef  tea,  milk  or  eggnog  must  be  given  at  reg- 
ular intervals  to  assist  the  action  of  the  stimulants  in 
sustaining  the  heart's  action. 

Digitalis,  strophanthus,  strychnin  and  atropin  in 
small  doses  are  excellent  cardiac  tonics  and  stimulants, 
and  are  indicated  in  cases  where  the  pulse  is  very  rapid 
and  soft,  denoting  a  feeble  peripheral  circulation  from 
a  weakened   heart. 

SAPREMIA. 

Sapremia  is  caused  by  the  absorption  of  ptomains 
from  putrefying  substances  in  the  body,  as,  for  instance, 
a  decomposing  blood  clot.     The  symptoms  pointing  to 


POR      THE      OPERATING      ROOM  115 

intoxication  usually  yield  promptly  to  the  removal  of 
the  putrefying  material  and  thorough  disinfection. 

PYEMIA. 

Pyemia  is  one  of  the  gravest  of  all  wound  complica- 
tions. It  develops  in  connection  with  a  suppurating 
focus,  and  is  indicated  and  characterized  by  severe  chills 
at  irregular  intervals  and  an  irregular  temperature.  If 
the  patient  lives  long  enough,  suppuration  in  one  or 
more  parts  of  the  body  is  to  be  expected.  The  general 
treatment  of  sapremia  and  pyemia  is  the  same  as  that  of 
septicemia. 


CHAPTER  XIV. 


INSTRUMENTS,  SUTURING  MATERIAL  AND  DRESSINGS 
REQUIRED  IN  SURGICAL  OPERATIONS. 

Surgeons  differ  in  their  methods  of  closing  an  ab- 
dominal incision.  Some  use  silver  wire,  others  silk, 
silkworm  gut  or  catgut,  as  suturing  material.  Some 
unite  the  incision  with  one  row  of  sutures,  which  are 
made  to  include  the  entire  thickness  of  the  margin  of 
the  wound.  Keith's  long  needles,  armed  with  the  silk- 
worm gut,  silk,  or  silver  wire,  are  best  adapted  for 
this  kind  of  suturing.  Most  surgeons  now  employ 
four  rows  of  sutures.  The  first  row  includes  the  peri- 
toneum, the  second,  the  fascia  of  the  recti  muscles,  the 
third,  the  skin  and  the  underlying  fat  tissues,  and  the 
fourth,  the  skin  only. 

The  peritoneum  is  sutured  with  very  fine  silk  or  ITo.  2 
catgut,  for  which  a  fine,  round,  curved  surgeon's  needle  is 
used.  The  second  row  consists  of  catgut  sutures,  No.  3, 
which  are  inserted  with  a  larger,  full-curved  needle. 
The  third  row  of  silkworm  gut  sutures  requires  a  large 
curved  surgeon's  needle.  The  horsehair  sutures  con- 
stitute the  fourth  row;  for  these  sutures  a  small  glov- 
er's needle  or  surgeon's  needle  answers  the  best  purpose. 
The  subcuticular  suture  (Halsted)  is  used  by  some  in 
uniting  the  skin.  These  are  fine  catgut  sutures,  from 
which  the  epidermic  layer  of  the  skin  is  excluded. 

GASTRO-ENTEROSTOMY. 

(Gastro-enterostomy:  Formation  of  a  new  opening  between 
stomach  and  intestine.) 

This  operation  is  required  for  patients  who  are  suf- 
fering from  carcinoma  or  cicatricial  stricture  of  pyloric 
orifice  of  the  stomach.  Required  for  the  operation  are 
the  following  instruments  and  suturing  material : 

Two  scalpels. 


FOE      THE      OPEKATING      ROOM  117 

Two  tissue  forceps. 

Two  artery  forceps  (8  inches). 

Eighteen  hemostatic  forceps. 

One  needle  holder. 

Murphy^s  button. 

McGraw^s  solid  rubber  cord. 

One  Kocher's  director. 

One  probe. 

One  blunt  hook. 

One  tenaculum. 

One  pair  small  blunt  retractors. 

One  pair  large  blunt  retractors. 

One  pair  scissors,  straight. 

One  pair  scissors,  curved,  blunt  point. 

One  pair  scissors,  curved,  sharp  point. 

One  pair   Senn's  perforated   decalcified  bone  plates 

(large  size). 
Ligatures  and  Sutures  : 

Catgut,  No.  1  and  No.  2,  ten  inches  long. 

Braided  silk,  No.  5,  ten  inches  long. 

Two  cambric  needles,  with  spring  eye,  for  Lembert 

sutures. 
Four  cambric  needles  for  braided  silk.  No.  5. 
Two  small  round,  curved  needles  for  catgut,  No.  2, 

for  peritoneal  sutures. 
Three  surgeon's  needles  for  catgut.  No.  3,  to  suture 

the  fascia. 
Three  glover's  or  surgeon's  needles  for  horsehair  for 

superficial  sutures. 
Six  glover's  or  surgeon's  needles  for  silkworm  gut 

for  deep  sutures. 
Dressings,  Etc.  : 

Boro-salicylic  acid  powder,  4:1. 
One-half  yard  sterilized  gauze. 
A  large  pad  of  sterilized  cotton. 
Abdominal  bandage. 
Perineal  straps  and  safety  pins. 
Collodion  in  an  aseptic  glass. 


118  A    nurse's     guide 

Camel's-hair  brush. 

Two  aseptic  adhesive  plaster  strips. 

Two  dozen  sterilized  towels. 

Twelve  sterilized  gauze  laparotomy  compresses. 

Supply  of  sterilized  gauze  sponges. 

Three  sterilized  sheets. 

One  sterilized  laparotomy  sheet. 

Bichlorid,  alcohol  and  physiologic  solution  for  the 
hands. 

The  Senn  bone-plates  may  be  purchased  already  pre- 
pared, but  the  sponges  that  are  in  the  bottle  in  which 
they  are  preserved  should  be  moistened  at  least  every 
six  months  with  a  solution  of  alcohol,  glycerin  and 
water,  equal  parts.  When  about  to  use  the  plates  wash 
in  carbolic  acid,  5  per  cent.,  and  rinse  in  physiologic 
solution.  The  lateral  or  fixation  sutures  are  attached 
to  a  cambric  needle  having  a  spring  eye. 


Senn's    Decalcified    Bone-plates. 

GASTROSTOMY. 

( Formation  of  a  stomach  fistula  made  necessarj'  in  carcinoma- 
tous and  in  some  cases  of  cicatricial  stricture  of  the  esophagus. ) 

The  fistula  is  made  for  the  purpose  of  introducing 
food  into  the  stomach.  Preparations  same  as  for  gastro- 
enterostomy, with  the  addition  of  a  non-fenestrated 
rubber  tube  the  size  of  a  large  catheter  and  eight  inches 
long  and  the  exclusion  of  Murphy's  button,  bone-plates, 
and  McGraw's  rubber  cord. 

GASTRECTOMY. 

(Excision  of  stomach.) 
The  same  preparations  as  for  gastro-enterostomy,  ex- 
cluding Murphy's  button,  McGraw's  rubber  cord   and 
bone-plates. 


FOR      THE      OPERATIlSrG      ROOM  H^ 

ILEOCOLOSTOMY. 
(Anastomosis   between   ileum   and   colon.) 

Prepare  second  size  plates,  instruments,  sutures,  etc., 
as  for  gastro-enter ostomy. 

INGUINAL  COLOSTOMY.     (Maydl's  Operation.) 

(Incision  of  colon  to  form  artificial  anus.) 

Two  scalpels. 

Two  tissue  forceps. 

Six  hemostatic  forceps. 

One  needle  holder. 

One  Kocher's  director. 

One  probe. 

One  pair  blunt  hook  retractors. 

One  pair  deep  hook  retractors. 

Three  pairs  scissors. 

Glass,   cylinder,    size   of    a   large   lead   pencil,    three 
inches  long,  covered  with  iodoform  gauze,  which 
should  project  well  beyond  the  ends  of  the  glass 
tube. 
Sutures  : 

Three  small,  round,  curved  needles  for  braided  silk, 
jSTo.  4,  to  suture  the  peritoneum  to  the  colon. 

Two  surgeon's  needles  and  two  glover's  needles  in  re- 
serve. 

Unless  the  symptoms  are  urgent,  the  colon  is  an- 
€hored  in  the  abdominal  incision  by  the  first  operation 
and  the  bowel  is  not  opened  until  the  second  or  third 
day  after  adhesions  have  formed.  For  the  second  opera- 
tion prepare  a  square  of  oiled  silk  or  gutta-percha 
tissue,  6x6  inches,  with  circular  f enestrum  in  center ; 
seal  edges  with  chloroform  to  protect  the  wound;  the 
cotton  under  the  impermeable  cover  is  sealed  with-  col- 
lodion. 

One  tenotome. 

Two  tissue  forceps. 

Two  hemostatic  forceps. 


■^ss 


120  A      NURSES      GUIDE 

A  pad  of  cotton. 

Hygroscopic  gauze  and  bandage. 

Sterilized   sheets,   towels,   gauze   sponges   and   gauze 
compresses. 

HERNIOTOMY. 
(Operation  for  strangulation  and  radical  cure.) 

Umbilical  hernia,  inguinal  hernia,  femoral  hernia, 
and  ventral  hernia. 

Hernia  is  a  protrusion  of  a  viscus  from  its  normal 
position.  Viscus  is  any  organ  of  the  thorax  or  abdomen. 
(Hernia  may  also  occur  in  various  parts  of  the  body.) 

Two  scalpels. 

One  bistoury,  curved,  probe  pointed. 

Two  tissue  forceps. 

Two  hemostatic  forceps,  long. 

Eighteen  hemostatic  forceps. 

One  needle  holder. 


Hydrocele    Trocar. 

One  pair  retractors,  small. 
One  pair  retractors,  large. 
Three  pairs  scissors. 
One  pedicle  needle. 
One  Kocher's  director. 
One  probe. 
One  tenaculum  hook. 
One  blunt  hook. 
One  hydrocele  trocar. 

Ligatures  : 

Catgut,  No.  2,  twenty  inches  long,  for  pedicle  needle, 
for  double  ligature,  used  to  ligate  the  sac  and  the 
omentum  when  it  is  diseased  or  can  not  be  re- 
duced.   (Braided  silk  is  sometimes  used.) 
Sutures  : 

Three   cambric  needles   for  braided   silk,   No.  4,   to 
suture  the  intestine  if  resection  is  made. 


FOR      THE      OPERATING      ROOM  121 

Three   small   curved  needles   for   catgut.    No.    3,   to 

suture    fascia    of    pectineus    muscle   to    Poupart's 

ligament,  in  femoral  hernia. 
(A  hernial  protrusion  below  Poupart's  ligament  con- 
stitutes a  femoral  hernia,  which  is  more  common  in 
women.) 

Three  small  round  curved  needles  for  catgut,  No.  2, 

to  suture  peritoneum. 
Six  glover's  or  surgeon's  needles  for  silkworm  gut 

for  wound  sutures. 
Two  glover's  or  surgeon's  needles  for  horsehair  for 

superficial  sutures. 

Dressing  : 

Boro-salicylic  acid  powder,  4:1,  with  collodion  dress- 
ing. 

Sterilized  sheets,  towels,  gauze  sponges,  gauze  com- 
presses, safety  pins,  bandages  and  cotton. 

Bichlorid  solution,  alcohol,  plenty  of  hot  and  cold 
normal  saline  solution  for  the  hands. 

APPENDECTOMY. 

(Excision  of   appendix   vermiformis   for   appendicitis.) 

Two  scalpels. 

Two  tissue  forceps. 

Four  hemostatic  forceps,  long. 

Eighteen  hemostatic  forceps. 

Three  pairs  scissors. 

One  needle  holder. 

One  pedicle  needle. 

One  pair  small  retractors. 

One  pair  large  retractors. 

One  Kocher's  director. 

One  grooved  director. 

Sterile  toothpick  tipped  with  cotton  to  apply  carbolic 
acid,  95  per  cent.,  to  cauterize  the  mucous  mem- 
brane of  the  stump  of  the  appendix. 

Iodoform  for  the  stump. 


123  A    nurse's     guide 

Ligatures : 

Catgut,  jSTo.  2,  or  braided  silk,  No.  5,  20  inches  long, 
for  pedicle  needle,  used  to  tie  off  the  adhesions  and 
the  appendix. 

Catgut,  ten  inches  long,  for  single  ligatures. 
'Sutures  : 

Catgut,  No.  1,  for  cambric  needle,  or  braided  silk, 
No.  4,  used  to  bury  the  stump  of  the  appendix  by 
suturing  over  it  the  adjacent  serous  surfaces.  For 
this  purpose  the  purse-string  suture  of  silk  or  cat- 
gut is  now  frequently  resorted  to. 

(In  all  cases  in  which  pus  is  found,  large  fenestrated 
tubular  drains  must  be  kept  in  readiness.) 

Six  glover's  needles  for  silkworm  gut  for  deep  sutures. 

Two  small  round  curved  needles  for  catgut,  No.  1,  or 
fine  silk  for  peritoneal  sutures. 

Two  small  round  curved  needles  in  reserve. 

Two   rubber   drains   and   narrow   strips   of   iodoform 
gauze  for  capillary  drainage. 
Dressing^  Etc.  : 

Boro-salic3'lic  acid  powder,  4:1. 

Sterilized  gauze,  one  yard. 

A  large  pad  of  sterilized  cotton. 

Two  aseptic  adhesive  plaster  strips. 

Abdominal  bandage.  , 

Perineal  straps. 

Twelve  sterilized  towels. 

Twelve  sterilized  gauze  compresses. 

Twelve  sterilized  safety  pins. 

Three  sterilized  sheets. 

One  sterilized  laparotomy  sheet. 

Supply  of  sterilized  gauze  sponges. 

Collodion  in  an  aseptic  glass  and  camel's-hair  brush. 

Bichlorid  solution,  1:1000,  alcohol  and  physiologic 
solution  for  the  hands. 


POR      THE      OPERATING      ROOM 


123 


CHOLECYSTENTEROSTOMY. 

(Formation   of   a   communication  between   the   gall   bladder 
and  the  upper  part  of  the  small  intestine.) 

Two  scalpels. 

Two  tissue  forceps. 

Two  Billroth's  hemostatic  forceps. 

Murphy's  button,  small. 

Two  long  hemostatic  forceps. 

Eighteen  hemostatic  forceps. 

Six  Tait's  hemostatic  forceps. 

Three  pairs  scissors. 

One  Kocher's  director. 

One  grooved  director. 

One  needle  holder. 


Murphy's    Button. 


Open. 


Closed. 


One  pair  small  retractors. 

One  pair  large  retractors. 

Exploring  syringe. 

Large  and  small  probes. 

Fenestrated  dull  curette. 

Small  curved  forceps. 
Ligatures  : 

Catgut,  ISTo.  2,  ten  inches  long. 
Sutures : 

Three  round  curved  needles  for  braided  silk,  No.  7. 
Three  cambric  needles  for  fine  silk. 
Six  surgeon's  needles  for  silkworm  gut  for  deep  su- 
tures. 


124  A    nurse's    guide 

Dressing^  Etc.: 

Sterilized  gauze,  pad  of  sterilized  absorbent  cotton, 
aseptic  adhesive  plaster  strips,  abdominal  bandage, 
perineal  straps,  safety  pins,  sheets,  towels,  gauze 
compresses,  gauze  sponges. 

CHOLECYSTOTOMY. 

(Opening  of  the  gall  bladder.) 

Cholecystotomy  in  two  stages.  In  these  cases  the 
gall  bladder  is  anchored  by  suturing  with  fine  round 
curved  needles  and  braided  silk,  No.  5,  to  the  parietal 
peritoneum  and  the  wound  tamponed  with  iodoform 
gauze.  On  the  third  day,  adhesions  having  formed,  the 
gall  bladder  is  opened  and  drained.  It  is  well  in  every 
case  of  gall  bladder  operation  to  prepare  the  following: 

One  tenotomy  knife. 

One  small  dull  curette. 

One  sharp  curette. 

Rubber  tubing  for  drainage. 

CHOLECYSTOSTOMY. 

(Formation  of  a  biliary  fistula  for  obstruction  of  cystic  or 
common  bile  duct  caused  by  biliary  calculus,  cicatricial  steno- 
sis or  malignant  diseases.) 

Operation  is  performed  frequently  for  the  removal 
of  gallstones.  Preparation  same  as  for  cholecystenteros- 
tomy.  In  all  operations  upon  the  gall  bladder  an  explor- 
ing syringe  and  bottle  aspirator  should  be  kept  in 
readiness  and  in  good  working  order. 

CHOLECYSTECTOMY. 

(Excision  of  gall  bladder.) 
Requirements  same  as  for  cholecystenterostomy, 
minus  the  Murphy  button  and  curettes,  with  the  addi- 
tion of  one  pedicle  needle  and  braided  silk,  No.  8,  or 
catgut,  No.  4.  twenty-four  inches  long,  two  pedicle  for- 
ceps, and  sterile  toothpick  with  one  point  charged  with 
pure  carbolic  acid. 


Potain's  Aspirator,   with   Bottle. 


CHAPTER  XV. 


GYNECOLOGIC    OPERATIONS— UTERINE    CURETTAGE. 

(Scraping  the  interim-  of  the  uterus.) 

One  small  uterine  dilator. 

One  large  uterine  dilator. 

One  sharp  curette. 

One  dull  curette. 

One  uterine  sound. 

One  uterine  probe. 

One  dressing  forceps. 

One  uterine  applicator  tipped  with  cotton. 

Two  vaginal  retractors. 

One  tenaculum  forceps. 

One  vulsellum  forceps. 

One  pair  scissors. 

Two  tenaculum  hooks. 

One  intrauterine  douche  tube. 

One  tissue  forceps. 

Four  hemostatic  forceps  or  sponge  holders. 

Tincture  of  iodin,  vaselin,  gij^cerin,  iodoform  powder, 
iodoform  gauze  strips,  sterile  lamb's  wool  and  cot- 
ton.  Either  of  the  latter  may  be  used  for  tampons. 

Corrosive  sublimate  solution,  1:4000,  boric-acid  solu- 
tion, 2  per  cent. ;  one-half  gallon  each  for  irriga- 
tion. 

Gynecologic  suit,  Dudley's  pad.  eight  sterilized 
towels,  three  sheets,  leg  holders,  sterilized  gauze 
sponges,  perineal  dressing. 

Caution. — The  intrauterine  douche  tube  is  a  very 
useful,  though  dangerous,  instrument  in  the  hands  of 
an  unskilled  nurse. 


Dudley's   Pad. 


Wig^more's    Intrautei-ine    Douche    Tube. 


Speculum. 


Leonard's   Dilator,    Small. 


Wathen's   Dilator,   Large. 


FOR      THE      OPERATING      ROOM  139 

PREPARATION   AND   USE. 

First. — Boil  for  fifteen  minutes  in  soda  solution. 

Second. — Expel  the  air  by  allowing  the  solution  to 
run  freely  before  inserting. 

Third. — Do  not  insert  beyond  the  shield. 

Fourth. — Hold  in  position  while  using. 

Fifth. — Use  no  force. 

Sixth. — Attach  a  rubber  tube  to  the  back-flow  can- 
ula  and  provide  a  basin  for  the  escaping  fluid. 

PERINEORRHAPHY  AND  TRACHELORRHAPHY. 

(Perineorrhaphy:     Suture  of  the  perineum.) 
(Trachelorrhaphy:     Suture  of  the  cervix.) 
Two  scalpels. 
Two  tissue  forceps. 
Twelve  artery  forceps,  Kocher's. 
Senn's  bullet  forceps. 


Senn's    Bullet   Forceps. 

One  vulsellum  forceps. 
One  tenaculum  forceps. 
One  needle  holder. 
Two  tenaculum  hooks. 

Two  pairs  scissors,  straight  and  curved  on  the  flat. 
One  uterine  dressing  forceps. 
One  uterine  sound. 
One  uterine  douche  tube. 
Two  vaginal  retractors. 
Ligatures : 

Catgut,  fine  and  medium,  ten  inches  long.    If  silk  is 
called  for.  give  No.  5  and  No.  7. 


Emmet's  Plain  Applicator. 


Sim's   Uterine   Probe. 


Simpson's    Uterine    Sound. 


Utei-ine  Curette.  Sharp. 


Uterine  Curette:   Dull. 


for    the    0  p  e  r  a  t  i  x  g    room  131 

Sutures  : 

Two  Hagedorn  needles  (full  curve)  for  braided  silk. 
No.  8,  for  st,ay  sutures. 

Two  surgeon's  needles  (full  curve)  for  medium  cat- 
gut. 

Two  curved  round  needles  for  medium  catgut. 

Three  full-curved  Emmet's  needles  for  catgut. 

Three  Emmet's  needles,  quarter-curved^  for  silkworm 
gut. 

Bichlorid  solution^  1  :-iOOO^  for  irrigation. 

Boric-acid  solution,  2  per  cent.,  for  irrigation. 

Vaselin  (hand  vaselin  on  an  aseptic  sponge). 

Pure  iodoform. 

Dressing^  Etc.  : 

Five  strips  of  iodoform  gauze,  three  inches  in  width. 

Two  strips  of  iodoform  gauze,  eight  inches  in  width. 

Sterilized  cotton  pad. 

"T"  bandage. 

Leg  holders. 

Eight  sterilized  towels. 

Three  sterilized  sheets. 

Sterilized  gauze  sponges. 

Gynecologic  suit. 

If  the  leg  holders  are  not  convenient,  fold  a  sheet  in 
triangular  shape,  roll  it  towards  the  point,  place  under 
the  knees  of  the  patient,  drawing  them  up,  bring  one 
end  over  the  shoulder  and  under  the  opposite  arm  and  tie. 

After  operation,  a  towel  should  be  pinned  around 
the  limbs  to  hold  them  in  position.  These  patients  are 
confined  to  light  diet  for  a  few  days. 

COLPORRHAPHY, 

(Suture  of  the  vagina,) 

Same  preparation  as  for  perineorrhaphy. 


132 


A      NUKSE'S      GUIDE 


VAGINAL  HYSTERECTOMY. 
(Kxcision  of  uterus.    Removal  of  uterus  through  the  vagina.) 

One  scalpel. 
One  bistoury. 
Two  tissue  forceps. 
Two  Tulsellum  forceps,  six  pronged. 
Two  vulsellum  forceps,  four  pronged. 
Two  vulsellum  forceps,  two  pronged. 
Eight  clamp  forceps,  eight  inches. 
Eight  Kocher's  arterj^  forceps. 
Pozzi's  hysterectomy  forceps. 


Pozzi's  Hystprectomy  Clamn. 

Four  long,  curved,  artery  forceps,  Pean's. 
Three  long,  curved,  artery  forceps,  Spencer  Wells. 
One  uterine  dressing  forceps. 
Two  pairs  vaginal  retractors. 
One  pair  scissors,  curved,  blunt  pointed. 
One  pair  scissors,  curved,  sharp  pointed. 
One  pair  scissors,  straight. 
Two  Sim's  specula  in  reserve. 
Two  tenaculum  hooks. 
One  pedicle  needle. 
One  Sims'  self-retaining  catheter. 
One  elastic  rubber  catheter. 
Ligatures  : 

Catgut,  No.   4  and   Xo.   .5,  twenty-four  inches  long, 
for  two  pedicle  needles  for  double  ligature. 


FOR      THE      OPERATING      ROOM  133 

Catgut,  No.  2  and  No.  3,  ten  inches  long,  for  single 
ligatures.  If  silk  is  called  for,  give  No.  7  or  No.  8, 
same  length. 

Sutures   may   be    required.     Prepare     round     curved 
needles,  small,  medium  and  large,  for  catgut. 
Dressing,  Etc.  : 

Six  strips  of  iodoform  gauze,  eight  inches  in  width. 

Three  strips  of  iodoform  gauze,  three  inches  in  width. 

Hygroscopic  gauze. 

Sterilized  cotton  pad. 

"T"  bandage. 

Gynecologic  suit. 

Three  sheets. 

Eight  towels. 

Gauze  sponges. 

Dudley  or  Kelly's  pad. 

Leg  holder. 

Solutions  : 

Boric  acid,  3  per  cent. ;  bichlorid,  1 :4000.  One-half 
gallon  of  each  for  irrigation. 

OOPHORECTOMY  OR  SALPINGO-OOPHORECTOMY. 

(Excision   of   Fallopian  tube   and   ovary   for   pyosalpinx.) 

HYSTEROPEXY. 

(Abdominal  Fixation  of  Uterus.) 

Pyosalpinx,  pus  in  the  Fallopian  tube;  hydrosalpinx, 
water  in  the  Fallopian  tube;  ovarian  tumor,  solid, 
cystic  Qr  dermoid. 

Two  scalpels. 

Two  tissue  forceps. 

Six  long  hemostatic  forceps. 

Twenty-four  hemostatic  forceps. 

One  needle  holder. 

Two  curved  pedicle  forceps. 

Two  vulsellum  forceps,  two  pronged. 

One  "T"-shaped  artery  forceps. 

One  pedicle  needle. 


134  A      NUKSE'S      GUIUK 

One  Kocher's  director. 

One  grooved  director. 

One  exploring  syringe. 

One  bottle  aspirator. 

Eubber  drains. 

Two  glass    drains    (Keith's)    lightly    packed   with   a 

strip  of  iodoform  gauze. 
Tliree  pairs  scissors. 
One  pair  deep  retractors. 
One  pair  small  retractors. 
One  small  probe. 

LiGATUKES : 

Catgut,  No.  2,  ten  inches  long,  for  single  ligatures. 
Catgut,  No.  4  and  No.  5,  twenty-four  inches  long,  for 

pedicle  needle  for  double   ligatures.     (If  braided 

silk  is  called  for,  give  No.  8,  the  same  length.) 
Sutures : 

Six  glover's  or  surgeon's  needles  for  silkworm  gut  for 

deep  sutures. 
Two  round  curved  needles  for  catgut,  No.  1,  or  fine 

silk  for  peritoneal  sutures. 
Two  surgeon's  needles  for  catgut,  No.  3,  for  fascia 

sutures. 
Two  glover's  needles  for  horsehair  for  skin  sutures. 
Two   cambric  needles   and  two   small   round   curved 

needles  in  reserve. 
Dressing,  Etc.  : 

Boro-salieylic  acid  powder,  4:1. 

One  yard  sterilized  gauze. 

Pad  of  sterilized  cotton. 

Aseptic  adhesive  plaster  strips. 

Abdominal  bandage. 

Perineal  straps  and  safety  pins. 

Twelve  sterilized  towels. 

Twelve  sterilized  gauze  compresses. 

Three  sterilized  sheets. 

One  sterilized  laparotomy  sheet. 


FOR      THE      OPERATING      R  0  0  il 


135 


For  ovarian  tumor  prepare  one  ovarian  trocar  with 
rubber  tubing  attached  and  two  cyst-holding  forceps. 
(Senn's  bullet  forceps.) 


Emmet's  Cyst  Trocar. 

ABDOMINAL  HYSTERECTOMY  OR  HYSTEROMYOMEC- 
TOMY. 

(Removal  of  the  body  of  the  uterus  for  cancer  or  myoma  by 
the  abdominal  route.  Removal  of  tumors  of  the  uterus  by 
same  route.) 

Hysterectomy  for  carcinoma  of  the  uterus  is  per- 
formed either  through  the  abdomen  or  vagina,  or  both 
operations   are   combined.     Eequirements   same  as  for 


Spencer   ^^'ells'    Pedicle   Forceps. 

the  preceding  case^  minus  the  trocar,  with  the  addition 
of  the  following: 

Four  cambric  needles  for  catgut.  No.  4. 

Three  large  round  curved  needles  for  catgut,  No.  4. 

Four  long  straight  hemostatic  forceps. 

Four  long  curved  hemostatic  forceps. 

Aseptic  rubber  cord  or  tubing  for  uterine  constrictor. 


13G  A     nurse's     guide 

MYOMECTOMY. 

(The  removal  of  a  uterine  tumor  by  enucleation  either  by 
the  vaginal  or  abdominal  route.) 

Preparation  the  same  as  for  Cesarean  section,  minus 
the  obstetrical  appliances. 

CESAREAN  OPERATION. 

(Removal  of  usually  living  child  by  abdominal  incision.) 

The  Porro  operation  accomplishes  the  same,  but  in- 
cludes at  the  same  time  the  supravaginal  removal  of 
the  uterus. 

Two  scalpels. 

Two  tissue  forceps. 

Two  hemostatic  forceps,  long. 

Twenty-four  hemostatic  forceps. 

Six  hemostatic  forceps,  Tait's. 

One  "T^^-shaped  arter}^  forceps. 

Two  pedicle  forceps. 

One  pair  retractors,  large. 

One  pair  retractors,  small. 

One  Kocher's  director. 

One  grooved  director. 

One  pedicle  needle. 

One  needle  holder. 

One  elastic  constrictor  of  rubber  cord  or  tubing. 

Three  pairs  scissors. 

One  uterine  dressing  forceps. 

One  Sims  speculum. 
Ligatures : 

Catgut.  No.  2  and  No.  3,  ten  inches  long. 
Sutures : 

Three  cambric  needles  for  catgut,  jSTo.  4,  or  fine  silk, 

to  suture  the  uterus. 
Three  large  curved  round  needles  for  catgut,  No.  4. 
Six  glover's  or  surgeon's  needles  for  silkworm  gut 

for  deep  sutures. 


FOE      THE      OPERATING      ROOM  137 

Two   glover's   needJes   for   horsehair    for    superficial 

sutures. 
Two  round,  curved  needles  for  catgut,  jSTo.  1,  or  fine 

silk,  to  suture  the  peritoneum. 
Two  surgeon's  needles  for  catgut,  jSTo.  3,  to  suture 

the  fascia. 
Two  fine,  round,  curved  needles  and  two  fine  cambric 

needles  in  reserve. 
One-half  yard  of  braided  silk  to  tie  the  umbilical 

cord. 
Fluid  extract  of  ergot,  olive  oil,  toilet  powder  and  a 

warm  blanket. 

Dressing  : 

Boro-salicylic   acid   powder,  4:1. 
One-half  yard  of  sterilized  gauze. 
Pad  of  sterilized  absorbent  cotton. 
Aseptic  adhesive  plaster  strips. 
Abdominal  bandages. 
Perineal  straps. 

Collodion  in  an  aseptic  glass  and  camel's-hair  brush. 
Twelve  sterilized  towels. 
Twelve  sterilized  safety  pins. 
Twelve  sterilized  laparotomy  sponges. 
Supply  of  sterilized  gauze  sponges. 
Three  sterilized  sheets. 
One  sterilized  laparotomy  sheet. 
Strips  of  iodoform  gauze,  3  and  8  inches  in  width. 
Perineal  dressing  consists  of  a  pad  of  sterilized  ab- 
sorbent cotton,  covered  with  sterilized  gauze,  and 

"T"  bandage. 

* 
Solutions  : 

Corrosive  sublimate  solution,  1 :1,000,  alcohol,  and  a 
liberal  supply  of  hot  saline  solution  for  hand  and 
surface  disinfection. 


138  A      X  U  R  S  E  '  S      GUIDE 

OBSTETRIC  NOTES. 

(Promptitude  in  answering  a  call.) 

"It  is  during  the  first  stage  of  labor  that  the  nurse  is 
likely  to  be  summoned,  and  slie  should  answer  the  call 
as  promptly  as  possible  so  as  to  have  time  to  make  all 
necessary  preparation  for  the  birth  of  the  child  without 
hurry." — Clara  Weeks. 

jSTurse's  obsteric  bag  should  contain : 

Thermometers  (clinical  and  bath). 

Ether  cone. 

Hypodermic  syringe. 

Medicine  dropper. 

Graduated  medicine  glass. 

A  glass  and  a  rubber  catheter. 

Fountain  syringe. 

Scissors  and  forceps. 

Bottle  of  bichlorid  tablets. 

Small  bottle  of  acetic  acid. 

Boric  acid,  two  ounces. 

Carbolic  acid. 

Small  package  of  absorbent  cotton. 

Braided  silk,  tape  or  cord. 

Safety  pins,  two  sizes. 

Sterilized  gown. 

If  previous  arrangements  have  been  made  with  the 
expectant  mother,  the  nurse  will  frequently  be  asked  to 
make  a  list  of  articles  needed,  so  that  ample  provision 
may  be  made.  The  following  contains  the  essential  ar- 
ticles, but  a  more  ample  one,  according  to  the  means  or 
taste  of  the  individual  may  be  given : 

For  the  Baby  Will  Be  Needed  : 

Blanket. 

Pair  of  round  pointed  scissors,  not  too  sharp,  to  cut 
the  umbilical  cord,  and  tape  or  braided  silk  with 
which,  to  tie  it.    (Heavy  Chinese  silk  is  the  best.) 

Bottle  of  olive  oil. 

Castile  soap. 


FOR      THE      OPERATING      ROOM  139 

Absorbent  cotton. 

Small  soft  sponge. 

Box  of  talcum  powder. 

Four  dozen  cotton  diapers  in  four  sizes. 

Four  flannel  bands,  eighteen  inches  long  and  about 
six  inches  wide. 

Four  long-sleeved  flannel  shirts. 

Six  flannel  skirts. 

Eight  plain  slips. 

Several  soft  flannel  wraps. 

Two  dozen  nickel-plated  safety  pins. 
For  the  Mother: 

Four  or  six  plain  night  dresses. 

One  or  two  flannel  wrappers  of  light  material. 

One  pound  of  sterilized  absorbent  cotton. 

Two  rolls  of  sterilized  gauze. 

Six  muslin  bandages. 

Eubber  sheet. 

Bed-pan. 

Three  basins. 

Fountain  syringe. 

Sterilized  glass  catheter. 

Ice. 

Brandy,  ergot,  chloroform,  ether. 

The  parturient  woman  must  be  regarded  in  the  light 
of  a  surgical  case,  and  everything  that  is  brought  in 
contact  with  the  genitals  must  be  aseptic.  Careful 
hand  disinfection  and  the  use  of  sterilized  absorbent 
dressings  are  as  important  here  as  in  the  treatment  of 
wounds. 

For  the  Doctor  : 

A  supply  of  sterilized  towels. 

A  sterilized  nail  brush. 

A  liberal  supply  of  hot  and  cold  sterilized  water. 

Tablets  of  corrosive  sublimate. 

Alcohol. 


CHAPTER  XVI. 


OPENING  OF  AN  ABSCESS. 

(An  abscess  is  a  circumscribed  cavity  containing  the  fluid 
product  of  suppurative  inflammation.) 

The  nurse  must  here  remember  the  aseptic  precau- 
tions to  be  observed,  in  order  to  prevent  further  infec- 
tion or  mixed  infection^  and  must,  therefore,  disinfect 
the  skin  sufficiently  far  beyond  the  line  of  incision. 

One  scalpel. 

One  bistoury. 

One  tissue  forceps. 

One  probe. 

One  sharp  spoon. 

One  pair  scissors. 

Three  hemostatic  forceps. 

One  glass  syringe. 

Fenestrated  rubber  drains. 
Solutions  : 

Peroxid  of  hydrogen,  bichlorid,  1 :3000,  for  irrigation. 
Prepare  iodin,  1  per  cent. 
Dressing,  Etc.  : 

A  heavy  compress  of  hygroscopic  gauze  moistened 
with  saturated  solution  of  acetate  of  aluminum, 
hot. 

Waxed  paper  or  oiled  muslin,  cotton,  bandages,  safety 
pins. 

Wounds  that  suppurate  profusely  are  dressed  every 
day  and  sometimes  twice  a  day.  Heat  and  moisture  in 
the  form  of  hot  antiseptic  fomentations  relieve  pain, 
reduce  swelling  and  inhibit  suppuration. 


FOR      THE      OPERATING      ROOM  141 

OPERATION  FOR  HARELIP. 

(Harelip:  Congenital  fissure  of  lip.) 

If  the  operation  is  performed  without  an  anesthetic, 
the  child's  arms  must  be  fastened  to  the  sides  of  the 
body  with  a  towel  or  a  broad  bandage  held  in  place  with 
safety  pins. 

One  tenotome. 

One  scalpel. 

One  needle  holder. 

One  Kocher^s  director. 

One  probe. 

One  pair  sharp  retractors. 

Two  tissue  forceps. 

Two  tenaculum  hooks. 

Two  blunt  hooks. 

Two  pairs  scissors. 

Six  artery  forceps. 
Sutures : 

Three  surgeon's  needles  for  catgut,  No.  1. 

Three  glover's  needles  for  silkworm  gut. 

Three  glover's  needles  for  horsehair. 
Dressing^  Etc.  : 

Narrow  strip  of  sterilized  gauze. 

Narrow  strip  of  adhesive  plaster. 

Cotton,  collodion  in  an  aseptic  glass,  camel's-hair 
brush,  safety  pins,  one-inch  roller  bandage,  six 
towels,  gauze  sponges. 

CHEILOPLASTY. 

(Plastic  operation  on  cheek.) 

Same  preparations  as  for  harelip. 

STAPHYLORRHAPHY. 

(The  suture  of  cleft-palate,  congenital  palatine  fissure, 
groove  or  cleft.) 

Whitehead's  gag. 

One  tenotome. 

One  staphylorrhaphy  knife,  double  edge,  sharp  point. 

One  staphylorrhaphy  knife,  double  edge,  probe  point. 


143 


NURSE     S      GUIDE 


One  staphylorrhaphy  knife,  curved,  probe  point. 

One  staphylorrhaphy  hook. 

One  needle  holder. 

One  tenaculum  hook. 

One  blunt  hook. 

One  periosteal  elevator,  curved. 

Two  tissue  forceps. 

Two  pairs  scissors. 

Six  hemostatic  forceps. 

Six  sponge  holders. 

Two  lead  discs  for  tension  suture. 

Silver  wire  and  silk  suture. 

Two  staphylorrhaphy  needles  with  handles. 

One  Kocher's  director. 


Whitehead's  Gag. 

One  probe. 

A  supply  of  small  sponges. 

Xarrow  strips  of  sterilized  and  iodoform  gauze. 

Thiersch's  solution  for  disinfection  of  iiioutli. 

RHINOPLASTY. 

(Plastic  operation  o7i  tlie  nose.) 

Two  scalpels. 

One  tenotome. 

Two  tissue  forceps. 

Twelve  hemostatic  forceps. 

One  Kocher's  director. 

One  grooved  director. 

One  probe. 

One  pair  sharp  retractors,  three  prong(!d. 

One  pair  sharp  retractors,  six  pronged. 


POR      THE      OPERATING      ROOM  143 

One  pair  scissors,  straight,  blunt  pointed. 
One  pair  scissors,  curved,  sharp  pointed. 
One  pair  scissors,  small. 
One  needle  holder. 
Ligatures : 

Catgut,  fine  and  medium,  ten  inches  long,  for  single 
ligatures. 

Sutures : 

Three  surgeon's  fine  needles,  full  curved,  for  fine  cat- 
gut, if  buried  sutures  are  required. 

Three  surgeon's  medium-sized  needles  for  medium- 
sized  braided  silk  for  tension  sutures. 

Three  surgeon's  needles  for  silkworm  gut  for  flap 
sutures. 

If  the  surgeon  takes  the  flap  from  the  forehead  pre- 
pare silver  Avire,  lead  plates,  perforated  shot,  forceps  to 
crush  the  lead  plates  (sequestrimi  forceps),  razor  and 
tvs^o  Tait's  forceps,  with  two  cambric  needles  used  to 
spread  the  grafts.  The  arm  or  thigh  of  the  patient  is 
prepared  according  to  the  method  given  for  surface 
disinfection  before  operation. 

When  the  flaps  are  taken  from  the  cheek,  the  skin- 
grafting  appliances  are  not  necessary. 

Dressing,  Etc.  : 

A  salt-solution  compress. 

Gutta-percha  tissiie. 

Absorbent  cotton. 

Bandage. 

Safety  pins. 

The  wound  from  which  the  grafts  are  taken  is  dressed 
according  to  the  method  given  for  the  skin-grafting  op- 
eration : 

Twelve   sterilized   towels. 

Sterilized  gauze  sponges. 


144  A    nurse's    guide 

TRACHEOTOMY. 

(Incision  of  the  trachea.) 

Two  scalpels. 

Two  tissue  forceps. 

Two  tenaculum  hooks. 

Two  blunt  hooks. 

Two  pairs  scissors. 

One  tracheotomy  tube. 

One  pair  three-pronged  retractors. 

One  probe. 

One  grooved  director. 

Six  hemostatic  forceps. 

SUTUEES : 

Two  surgeon's  needles  for  catgut  No.  2. 

Two  glover's  needles  for  silkworm  gut. 
Dressing^  Etc.  : 

Boro-salicylic  acid  powder,  4:1. 

Strips  of  sterilized  gauze. 

Gutta-percha  tissue  or  oiled  silk,  4x4. 

Two-inch  cotton  roller  bandage. 

Gauze  sponges. 

Two  pieces  of  narrow  tape,  each  11  inches  long.  At- 
tach one  strip  to  each  side  of  the  tracheotomy  tube,  and 
tie  around  the  neck  to  hold  the  tube  in  position.  The 
outer  tube  should  not  be  removed  by  the  nurse,  but  she 
removes  the  inner  one  every  hour,  or  oftener  if  so  di- 
rected by  the  physician.  The  movable  or  inner  tube 
should  be  washed  in  a  solution  of  salt  water  (one  dram 
of  salt  to  a  quart  of  water)  and  swabbed  out  with  a 
chicken  feather  or  cotton  mop  which  has  been  sterilized. 
Before  replacing  the  inner  tnbe,  the  tube  in  the  trachea 
should  also  be  cleaned,  to  remove  the  mucus  that  col- 
lects in  and  around  the  tube,  thus  rendering  free  the 
entrance  and  escape  of  air. 

The  temperature  of  the  tracheotomy  room  must  not 
be  less  than  80  degrees  F.,  and  the  atmosphere  should 
be  saturated  with  steam. 


Konig's  Lai'ge  Tracheal  Canula. 


Trousseau's  Double  Tracheotomy  Tube. 


Dwyer's    Intubation    Tubes. 


146  A      NURSE'S      GUIDE 

ADENECTOMY. 

(Excision   of   diseased   lymphatic   glands;    it    here   refers   to 
tubercular  glands  of  the  neck.) 

Two  scalpels. 

Two  tissue  forceps. 

Two  blunt  hooks. 

Two  tenaculum  hooks. 

Twelve  artery  forceps. 

One  pair  scissors,  straight,  blunt  pointed. 

One  pair  scissors,  curved,  blunt  pointed. 

One  pair  scissors,  curved,  sharp  pointed. 

One  pair  sharp  retractors. 

One  pair  blunt  retractors. 

One  artery  needle  (aneurysm  needle). 

One  probe. 

One  Kocher's  director. 

One  grooved  director. 

One  needle  holder. 

Ligatures  : 

Catgut  Xo.  1  and  No.  2.  ten  inches  long. 
Aneurysm  needle   for   catgut    iSTo.    2,   twenty   inches 

long,  for  ligation  of  large  lilood  vessels. 
Braided  silk  may  be  required. 
Sutures : 
Three  large,  curved,  round  needles  for  catgut  No.  4, 

for  muscle  suture. 
Two  surgeon's  needles  for  catgut  Xo.  2. 
Six  glover's  or  surgeon's  needles  for  silkworm  gut. 
Two  glover's  or  surgeon's  needles  for  horsehair. 
Two  fine,  round,  full-curved  needles  in  reserve. 

Drainage  : 

Three-inch    strip    of    iodoform    gauze   for   capillary 

drainage. 
Folded  gutta-percba  tissue  for  surface  drainage. 
Fenestrated  rubber  tubes. 


.    for    the    0  p  e  r  a  t  i  x  g    room         147 

Dressing,  etc.  : 

Boro-salicylic  acid  powder,  4:1. 

One-half  yard  of  sterilized  gauze. 

Large  pad  of  sterilized  cotton. 

Two  aseptic  gauze  roller  bandages. 

Two  plaster-of-Paris   roller   bandages. 

Six  sterilized  gauze  compresses. 

Ample  supply  of  sterilized  sponges. 

Twelve  sterilized  safety  pins. 

Twelve  sterilized  towels. 

Three  sterilized  sheets. 

Collodion  in  an  aseptic  glass,  and  camel's  hair  brush. 

SOLUTION'S  : 

lodin,  1  per  cent. 

Hot  and  cold  physiologic  solution. 

Iodoform  gtycerin  emulsion,  10  per  cent. 

MAMMECTOMY. 
(Excision  of  the  breast.) 

Two  scalpels. 

Two  tissue  forceps. 

One  needle  holder. 

One  aneurysm  needle. 

Two  blunt  hooks. 

One  pair  sharp  retractors. 

One  pair  deep  retractors. 

One  Kocher's  director. 

Three  pairs  scissors. 

Twenty-four  hemostatic  forceps. 
Ligatures : 

Catgut  ISTo.  2  and  ISTo.  3  ten  inches  long. 
Sutures : 

Two  surgeon's  needles  for  catgut  No.  2  for  buried 
sutures. 

Three  large  curved  surgeon's  needles  for  silk  No.  8 
for  tension  sutures. 

Six  glover's  or  surgeon's  needles  for  silkworm  gut. 

Three  glover's  needles  for  horsehair. 


148  A    nurse's    guide 

Drainage  : 

Strips  of  iodoform  gauze  three  inches  in  width. 

Strips  of  iodoform  gauze  eight  inches  in  width. 

Folded  gutta-percha  tissue  for  surface  drainage. 

Two  fenestrated  tubes,  large  and  medium. 
Dressing,  etc.: 

Boro-salicylic  acid  powder,  4 :1.  ■ 

Three  yards  of  sterilized  gauze. 

Large  pad  of  sterilized  cotton. 

Two  aseptic  gauze  roller  bandages,  7  inches  wide  and 
5  yards  long. 

Six  sterilized  gauze  compresses, 

A  supply  of  gauze  sponges. 

Twelve  sterilized  safety  pins. 

Twelve  sterilized  towels. 

Three  sterilized  sheets. 

Collodion  in  an  aseptic  glass,  and  camel's  hair  brush. 
Solutions  : 

Plenty  of  hot  and  cold  physiologic  solution. 

Corrosive  sublimate  solution,  1 : 1,000. 

NEPHROPEXY. 

(Nephropexy:      Fixation    of    the    kidney.      Nephrorrhaphy: 
Suture  of  kidney.) 

Two  scalpels. 

Two  tissue  forceps. 

Two  Senn's  bullet  forceps. 

Six  artery  forceps. 

Three  pairs  scissors. 

One  needle  holder. 

One  pair  small  retractors. 

One  pair  large  retractors. 

One  Kocher's  director. 

Ligatures  and  Sutures: 

Catgut  No.  2  and  No.  4. 

Three  round  curved  needles  for  catgut  No.  5,  or  silk, 

as  the  surgeon  may  direct,  with   which   to  suture 

the  kidney. 


FOR      THE      OPERATING      ROOM  149 

Two  glover's  or  surgeon's  needles  for  silkworm  gut. 
One  glover's  needle  is  used  to  scarffy  the  kidney. 
Dressing,  Etc.  : 

Six  three-inch  strips  of  iodoform  gauze  for  tampon- 
ing the  wound. 

Three  yards  of  sterilized  gauze. 

Large  pad  of  sterilized  cotton. 

Two  gauze  roller  bandages. 

Two  strips    adhesive   plaster   two   inches   wide,    and 
long  enough  to  encircle  the  body. 

Twelve  sterilized  towels. 

Eight  sterilized  safety  pins. 

Three  sterilized  sheets. 

Small  pad  four  inches  long,  three  inches  wide  and 
three  inches  thick,  made  of  cotton  or  gauze,  to  be 
placed  under  the  kidney  in  front  when  dressing  is 
applied. 
A  hard  circular  pillow,  two  feet  in  length,  eighteen 
inches  in  circumference,  covered  with  rubber  sheet- 
ing and  sterilized  towels. 

NEPHRECTOMY. 

(Excision  of  the  kidney.) 

Same   preparation   as    for   nephrorrhaphy,   with   the 
addition  of: 

Two  eight-inch  clamp  forceps,  straight. 

Two  eight-inch  clamp  forceps,  curved. 

One  pedicle  needle  for  strong  silk  or  catgut  No.  4, 

with  which  to  tie  the  pedicle. 
Exploring  syringe. 
Paquelin  cautery. 

VARICOTOMY. 

(Excision  of  varicose  veins.) 

Esmarch's  constrictor. 
Two  scalpels. 
Two  tissue  forceps. 
Twelve  hemostatic  forceps. 


150  A     nurse's     guide 

Two  tenaciihim  hooks. 

Two  blunt  hooks. 

One  needle  holder. 

One  artery  (aneurysm)   needle. 

One  probe. 

One  Kocher's  director. 

One  pair  sharp  retractors. 

One  pair  blunt  retractors. 

Two  pairs  scissors. 

Ligatures : 

Catgut    'No.    2.    twentr\^    inches    long,    for    aneurysm 
needle  to  ligate  veins. 
Catgut  No.  2,  ten  inches  long,  for  single  ligatures. 

Braided  silk  No.  5,  may  be  required. 

Sutures : 

Two  surgeon's  needles  for  catgut  No.  2  for  buried 

sutures. 
Six  glover's  or  surgeon's  needles  for  silkworm  gut. 
Two  glover's  needles  for  horsehair. 
Two  small  round  curved  needles  in  reserve. 

Drainage  : 

Two-inch  strips  iodoform  gauze  for  capillary  drain- 
age. 
Folded  gutta-percha  tissue  for  surface  drainage. 

Dressing,  etc.  : 

Boro-salicylic  acid  powder,  4:1. 
Sterilized  gauze. 
Large  pad  of  sterilized  cotton. 
Two  aseptic  gauze  roller  bandages. 
Posterior  hollow  splint,  well  padded. 
Sterilized  gauze  sponges. 
Twelve  sterilized  safety  pins. 
Twelve  sterilized  towels. 
Two  sterilized  sheets. 


you    the    operating    room  151 

Solutions  : 

Biehlorid  solution,  1 :1,000. 

Alcohol. 

Hot  and  cold  physiologic  solution. 

Kote. — The  limb  is  kept  in  an  elevated  position  until 
the  wound  is  healed. 

DERMATOPLASTY— SKIN  GRAFTING. 

This  operation  consists  in  transplanting  living  skin 
to  cover  cutaneous  defects  caused  by  injury,  operation 
or  disease.    Four  methods  are  employed : 

First.  Reverdin's  small  grafts  of  the  cuticle  only. 

Second.  Thiersch's  larger  grafts,  including  entire 
thickness  of  true  skin. 

Third.  Wolfe's  large  grafts  of  skin  devoid  of  subcu- 
taneous fat. 

Fourth.  Krause's  large  grafts  with  underlying  fat  tis- 
sue. 

Carefully  disinfect  the  skin  from  which  grafts  are  to 
be  taken  and  provide  the  following: 

Aseptic  razor. 

One  sharp  curette,  if  grafting  is  to  be  done  on  a 
granulating  surface. 

Two  artery  forceps. 

Two  cambric  needles. 

For  the  Wolfe  and  the  Krause  methods  a  sharp 
scalpel  and  a   dissecting  forceps  will  be  required. 

The  wounds  to  which  the  grafts  are  applied  should 
be  dressed  with  narrow  strips  of  gutta-percha  tissue, 
rendered  aseptic  by  washing  with  soap  and  water,  rins- 
ing thoroughly  in  sterilized  water,  immersing  in  two 
per  cent,  formalin  solution  for  one  hour;  again  rins- 
ing in  sterilized  water,  and  placing  in  physiologic  so- 
lution until  required  for  use. 

Sterilized  gauze,  cotton,  roller  bandage  and  safety 
pins. 

Kote. — Great  care  must  be  taken  in  applying  the 
bandage.     If  too  much  pressure  is  put  on  the  grafts 


152  A    nurse's    guide 

they  will  die.  These  wounds  are  sometimes  dressed  with 
a  light  compress  of  sterilized  gau^e  saturated  with  a 
warm  physiologic  solution  over  which  gutta-percha  tis- 
sue is  applied. 

A  quart  of  this  solution  should  also  be  provided  in  a 
basin,  into  which  the  sui'geon  may  dip  the  razor  before 
cutting  the  grafts. 

LITHOTOMY  BY  PERINEAL  SECTION. 

(Incision   into   the  bladder  through  the   perineum   for   stone.) 

One  scalpel. 

One  bistoury,  probe  pointed. 

Two  tissue  forceps. 

Two  artery  forceps,  8  inches  long. 

Twelve  artery  forceps,  Kocher's. 

One  Wheelhouse  staff. 

Two  lithotomy  forceps. 

Three  lithotomy  staffs. 

One  lithotomy   scoop. 

One  Kocher's  director. 

One  grooved  director. 

One  needle  holder. 

One  pair  scissors,  curved,  blunt  pointed. 

One  pair  scissors,  curved,  sharp  pointed. 

One  pair  scissors,  straight. 

One  pair  sharp  retractors. 

One  pair  blunt  retractors. 

One  blunt  hook. 

One  tenaculum  honk. 

One  probe. 

Three  steel  sounds. 

One  silver  catheter. 

Three  soft  rubber  catheters,  Nos.  7,  9  and  11.     (Nela- 

ton.) 
One  large  rubber  drain,  not  fenestrated. 


Vau   Buren's   Curved   Sound. 


"?__"'TTl't— '^^"^  '"—""""'''■""»■■■"-' 


Thompson's   Stone   Searcher. 


^^ 


Wheelhouse's    Staff. 


Litde's    Lithotomy    Forceps. 


I'.igelow's    Litliotrite. 


for    the    operating    room  155 

Ligatures : 

Catgut  Nos.  8  and  3,  ten  inches  long.     If  braided 
silk  is  called  for  supply  Nos.  5  and  8, 10  inches  long. 

Sutures : 

Two  surgeon's  needles  for  silkworm  gut. 

Two  round  curved  needles  for  catgut  No.  2. 

Two  small  curved  needles  for  braided  silk  in  reserve. 

Dressing,  Etc.  : 

Boro-salicylic  acid  powder  4:1. 

Iodoform   gauze   strips    three    and    eight    inches    in 

width. 
Sterilized    gauze,    cotton,    gauze    sponges    and    "T'* 

bandage. 
Eight  sterilized  towels. 
Three  sterilized  sheets. 
Gynecologic  suit. 
Boric-acid  solution,  2  per  cent,  for  irrigation. 

SUPRAPUBIC  LITHOTOMY. 

(Incision  above  pubes  into  the  bladder  for  stone.) 
Eequirements    the   same    as    for   perineal    lithotomy, 
omitting  the  staffs,  with  the  addition  of  the  following: 
Senn's  sigmoid  catheter  with  rubber  tubings  attached. 


Senn's   sigmoid    catheter   for   suprapubic    drainage    of   the    bladder. 

Bladder  syringe. 

Eectal  bag. 

Two  long  strips  of  adhesive  plaster. 

The  usual  abdominal  dressins;. 


156  A     nurse's     guide 

PROSTATECTOMY. 

(Excision  of  prostate  gland.) 

Prepare  same  as  for  perineal  section,  with  addition 
of  traction  forceps. 

OPERATION  FOR  PHIMOSIS. 

(Circumcision.) 
One  scalpel. 
One  tissue  forceps. 
One  needle  holder. 
One  probe. 
Two  pairs  scissors. 
Three  hemostatic  forceps. 

Sutures : 

Two  fine  surgeon's  needles  for  catgut  No.  1. 

Two  cambric  needles  in  reserve. 
Dressing,  etc.  : 

Boro-salicylic  acid  powder,  4:1. 

Vaselin. 

Narrow  strips  of  sterilized  gauze  and  gauze  sponges. 

Sterilized  cotton. 

Collodion  in  an  aseptic  glass,  and  camel's  hair  brush. 

Strips   of   adhesive  plaster   one-half   inch  wide   and 
seven  inches  long. 

Sterilized  towels. 

VARICOCELE. 

(Dilatation  of  the  spermatic  veins.) 
Two  scalpels. 
Two  tissue  forceps. 
Twelve  hemostatic  forceps. 
One  pair  sharp  retractors. 
One  pair  dnll  retractors. 
One  pair  blunt-pointed  scissors. 
One  pair  sharp-pointed  scissors. 
One  needle  holder. 
One  aneurysm   needle. 


FOR      THE      OPE  EATING      ROOM  157 

Koclier's  director. 

One  grooved   director. 

One  blunt  hook. 
Ligatures  : 

Aneurysm  needle  for  catgut  No.  2,  twelve  inches  long, 
to  ligate  dilated  veins. 

If  braided  silk  is  called  for,  supply  No.  5  or  No.  7. 
Sutures  : 

Two  surgeon's  needles  for  catgut  No.  2. 

Six  glover's  or  surgeon's  needles  for  silkworm  gut. 

Two  glover's  or  surgeon's  fine  needles  for  horsehair. 
Dressing,  Etc.  : 

Boro-salicylic  acid  powder,  4:1. 

Sterilized  gauze. 

Sterilized  cotton. 

Sterilized  gauze  sponges. 

Gutta-percha  tissue. 

Collodion  in  an  aseptic  glass,  and  camel's  hair  brush. 

G-auze  roller  bandage. 

Two    strips   adhesive   plaster   two    inches    wide    and 
twenty-four  inches  long. 

Three  sterilized  sheets. 

Twelve  sterilized  towels. 

RECTAL  FISTULA. 

(Abnormal  tube-like  passage  about  the  anus,  giving  vent  to 
pus  or  other  secretions.) 

Select  and  prepare  the  following  instruments: 

One  scalpel. 

One  bistoury. 

One  Sim's  speculum,  small. 

One  rectal  speculum. 

One  probe. 

One  grooved  director. 

One  pair  sharp  retractors. 

One  pair  blunt  retractors. 

One  sharp  spoon. 

One  needle  holder. 


158  A     xurse's     guide 

Two  pairs  scissors. 

Two  tissue  forceps. 

Six  hemostatic  forceps. 

One  glass  syringe  for  peroxid  of  hydrogen. 

Thiersch's  solution  for  irrigation. 

Dudley  or  Kelly's  pad. 

Gynecologic  suit. 

Paquelin  cautery. 

Ijeg  holders. 

One  rectal  tampon. 
Ligatures  : 

Catgut  No.  2. 
Sutures : 

Two  small  fistula  needles  for  catgut  No.  2. 

Three  surgeon's  needles  for  catgut  No.  3. 

Three  surgeon's  needles  for  silkworm  g-ut. 
Dressing,  Etc.  : 

Boro-salicylic  acid  powder,  4:1. 

Six  iodoform  gauze  strips. 

Sterilized  gauze,  cotton  and  "T"-bandage. 

Sterilized  sponges. 

Safety  pins. 

Eight  sterilized  towels. 

Three  sterilized  sheets. 

OPERATION  FOR   HEMORRHOIDS   BY  THE  USE   OF  THE 
CLAMP  AND   CAUTERY. 

(Hemorrhoids:       Swellings    caused    by    varicose    hemorrhoidal 
veins.) 

One  Sim's  speculum,  small. 
One  pile  clamp   (Adams'). 


Adams'    Hemorrhoid    Clamp. 


V  OR      THE      OPERATING      ROOM  159 

One  pair  scissors,  blunt  pointed. 

Six  Kocher's  artery  forceps. 

Paqnelin  cautery  in  good  working  order. 

Rectal  tampon. 

This  tampon  is  made  of  a  piece  of  rubber  tubing  the 
size  of  the  thumb,  and  twelve  inches  in  length,  covered 
with  iodoform  gauze.  Into  this  tube  is  inserted  a  glass 
cylinder  three  inches  in  length,  over  which  the  rubber 
tubing  should  extend  two  inches.  An  umbrella  of  iodo- 
form gauze  12x12  inches  is  fastened  to  the  tube  by 
tying  a  silk  ligature  over  it  at  a  point  corresponding 
with  the  glass  cylinder.  Strips  of  sterilized  gauze  are 
used  in  packing  the  space  between  the  tube  and  um- 
brella or  mantle  of  gauze  after  the  tube  has  been  in- 
serted into  the  rectum.  -i 

The  rectal  tampon  is  removed  forty-eight  hours  after 
operation.  During  this  time  the  patient  is  kept  on 
liquid  diet.  In  removing  the  tube  traction  is  made  on 
the  mantle  of  iodoform  gauze  until  the  packing  is 
brought  within  easy  reach,  when  it  is  removed  with  for- 
ceps, and  the  tube  can  be  extracted  without  causing  any 
pain. 

Bowels  should  be  evacuated  the  third  day  after  the 
operation.  For  this  purpose  castor  oil  is  generally  pre- 
ferred. 

Vaselin. 

Sterilized  gauze  sponges,  gauze  strips  three  and  eight 
inches  in  Avidth,  cotton,  and  "T"  bandage. 

Six  sterilized  towels. 

Leg  holders. 

Thiersch's  solution  for  irrigation. 

Gynecologic  suit. 

Dudley  or  Kelly's  pad. 

Paquelin  or  thermo-cautery  is  a  form  of  actual  cau- 
tery, in  which  the  heat  is  produced  by  blowing  benzine 
vapor  into  a  heated  platinum  point  (platinum:  silver- 
white,  almost  infusible  metal). 


160  A    xurse's    guide 

When  the  cautery  is  to  be  used,  the  nurse  should  test 
it  before  the  operation.  Never  blow  the  benzine  vapor 
into  the  platinum  point  until  the  point  is  well  heated 
in  the  flame  of  an  alcohol  lamp  or  Bunsen  burner ;  then 
commence  by  pressing  the  bulb  slowly.  Place  the  bottle 
containing  the  benzine  in  a  basin  of  hot  water ;  this  will 
hasten  the  heating  of  the  point.  See  that  the  rubber 
tube  through  which  the  benzine  vapor  is  conveyed  is 
not  twisted  or  doubled.  Next,  keep  the  platinum  point 
in  the  flame  until  it  is  well  heated.  Sometimes  the 
cause  of  the  cautery  not  working  is  due  to  the  benzine, 
which  should  be  renewed  frequently.  When  the  surgeon 
hiis  finished  with  the  cautery,  it  should  be  burned  out 
immediately.  This  is  done  by  placing  the  point  in  the 
flame  until  the  platinum  is  again  well  heated,  then 
quickly  removing  the  rubber  tube  attached  to  the  handle, 
and  pressing  the  tube  between  the  thumb  and  index 
finger  to  prevent  evaporation.  Great  care  must  be 
taken  in  handling  the  cautery,  as  the  benzine  is  highly 
inflammable.  When  in  use  the  handle  of  the  cautery 
should  bo  wrapped  with  moist  sterilized  gauze. 

\ 


Improved  Thermocautery. 


CHAPTER  XVII. 


OPERATIONS   ON   BONES   AND   JOINTS. 
CRANIECTOMY. 

(Opening   of   the   skull   for  cerebral   hemorrhage;    tumor   of 
the  brain,  or  fracture  of  the  skull,  or  epilepsy.) 

Two  scalpels. 

One  tenotome. 

Two  tissue  forceps. 

Eighteen  artery  forceps. 

One  Senn's  periosteal   elevator. 

One  large  trephine. 

One  small  trephine. 

One  De  A^ilbiss  bone-cntting  forceps. 

One  bone-cntting  forceps. 

Two  pairs   retractors,  sharp   and   blunt. 

One  fine  probe. 

Two  blunt  hooks. 

One  Kocher's  director. 

One  grooved  director. 

One  gouge. 

Two  chisels. 

One  mallet. 

One  needle  holder. 

One  small  bone  drill. 

Wilson's  cyrtometer. 

One  foot  of  silver  wire  to  serve  as  an  electrode  for 
the  galvanic  battery,  which  is  sometimes  used  when 
the  operation  is  for  epilepsy. 
Ligatures  and  Sutures: 

Catgut  Xo.  1  and  IsTo.  2,  or  fine  braided  silk. 

Two  small  round  curved  needles  for  catgut  to  su- 
ture the  dura  mater  (outer  membrane  of  the  brain 
and  spinal  cord). 


Wilson's   Cyrtometer. 


Conical  Trephine. 


De   Vilbiss   Trephine. 


164  A    nurse's    guide 

Two  surgeon's  needles  for  catgut  No.  2. 

Four  glover's  or  surgeon's  needles  for  silkworm  gut^ 

for  flap  sutures. 
Two  glover's  or  surgeon's  fine  needles  for  horsehair, 

for  superficial  sutures. 

Dressing^  Etc.  : 

A  few  strands  of  catgut  or  horsehair  are  sometimes 
used  for  drainage. 

Collodion  in  an  aseptic  glass,  and  camel's  hair  brush. 

A  large  aseptic  absorbent  dressing. 

Three  plaster-of-Paris  bandages. 
Solutions  : 

Tincture  of  iodin  and  a  probe  tipped  with  cotton. 

Physiologic  solution  at  a  temperature  of  100  de- 
grees ¥.,  in  which  to  preserve  bone  temporarily 
removed. 

Hot  physiologic  solution  at  a  temperature  of  1^0  de- 
grees F.  is  sometimes  called  for,  with  which  to  ar- 
rest troublesome  capillar}'-  hemorrhage. 

EXCISION  OF  MAXILLA— UPPER  AND  LOWER. 

(Maxilla — the  jaw.) 

Two  scalpels. 
•    Two  tissue  forceps. 
Two  artery  forceps,  long. 
Two  bone-cutting  forceps,  large. 
One  lion-jaAv  bone-holding  forceps. 
Eighteen  artery  forceps. 
One  periosteal  elevator  (Senn's). 
One  cross-cutting  bone  forceps. 
One  probe. 
Two  blunt  hooks. 
Two  tenaculum  hooks. 
Two  pairs  retractors,  sharp  and  hliiiil. 
Three  pairs  scissors. 


De    Vilbiss    Cranial    Forceps. 


Von    Brun's    Chisel. 


Macewen's  Gouge. 


Rryant's  Rawliida  Mallet. 


16C  A    nurse's     guide 

One  chain  saw. 


Chain   Saw. 


Two  chisels. 

One  gouge. 

One  wood  or  rawhide  mallet. 

One  Kocher's  director. 

Two  dental  forceps,  incisor  and  molar. 

One  needle  holder. 

Paquelin  canter}-. 

Ligatures  axd  Sutures  : 

Catgut,  ISTo.  2  and  ISTo.  3,  ten  inches  long. 

Two  surgeon's  needles  for  catgut,  medium,  for  muscle 

sutures. 
Two  surgeon's  needles  for  catgut,  fine,  to  suture  the 

mucous  membrane. 
One  surgeon's  large  curved  needle  for  silk,  No.  8,  for 

the  tongue. 
Six  glover's  or  surgeon's  needles  for  silkworm  gut  for 

the  flap. 
Two  glover's  or  surgeon's  fine  needles  for  horsehair 

for  superJicial  sutures. 

Drainage  : 

Mikulicz's  drain. 

Narrow  strips  of  iodoform  gauze. 

Eubber  tubing. 


for    the    operating    room 

Dressing,  Etc.  : 

Boro-salicylic  acid  powder,  4:1. 

One  yard  sterilized  gauze. 

Large  pad  sterilized  absorbent  cotton. 

Sterilized  gauze  sponges. 

Sterilized  gauze  comprevSses. 

Two  sterilized  gauze  roller  bandages. 

Twelve  sterilized  safety  pins. 

Twelve  sterilized  towels. 

Three  sterilized  sheets. 

One  ounce  of  compound  tincture  of  benzoin. 

RESECTION  OF  RIB  FOR  EMPYEMA. 
(Empyema:   Pus  in  pleural  cavity.) 

Two  scalpels. 
Two  tissue  forceps. 
Two  artery  forceps,  long. 
Six  artery  forceps. 
One  bone-cutting  forceps. 


IC? 


Liston's    Bone  cutting    Forceps. 


One  lion-jaw  holding  forceps. 
One  Senn's  periosteal  elevator. 


Senn's  Periosteal   Elevator. 


One  probe. 

One  Kocher's  director. 
One  grooved  director. 
Two  pairs  scissors. 
One  exploring  sjrringe. 


168  A     nurse's     guide 

Ligatures  and  Sutures  : 

Catgut,  No."  2. 

Two  surgeon's  needles  for  silkworm  gut. 

Two  glover's  needles. 
Dressing^  Etc.  : 

Boro-salicylic  acid  poAvder,  4:1. 

Strips  of  iodoform  gauze  three  inches  wide. 

Strips  of  iodoform  gauze  eight  inches  wide. 

Sterilized  gauze  sponges. 

Three  yards  sterilized  gauze. 

Large  pad  of  sterilized  cotton. 

Two  gauze  roller  bandages. 

Sterilized  safety  pins. 

Six  sterilized  towels. 

Three  sterilized  sheets. 

Two  large  rubber  tubular  drains. 

SEQUESTROTOMY. 

(Operation   foi-  the   removal   of   a   sequestrum,   fragment,   of 
necrosed  bone.) 

Esmarch's  constrictor. 
Two  scalpels. 
Two  tissue  forceps. 
Twelve  hemostatic  forceps. 
One  sequestrum  forceps. 
One  bone-cutting  forceps. 
One  periosteal  elevator. 
One  sharp  spoon,  small. 
One  sharp  spoon,  medium. 
One  sharp  spoon,  large. 
Two  gouges  (round  chisel). 
Two  chisels. 

One  wood  or  rawhide  mallet. 
One  Kocher's  director. 
One  grooved  director. 
Two  probes,  long  and  short. 
One  pair  sharp  retractors. 
One  pair  blunt  retractors. 


Volkmann's    Sharp   Spoons. 


Sequestrum  Forceps. 


Mathieus  Bone-holding  Forceps. 


170  A    nurse's     guide 

One  pair  scissors,  curved,  blunt. 
One  pair  scissors,  straight. 
Decalcified  bone  chips. 


DEGALCilFlED 
BONECHIPS 


Senn's  Decalcified  Bone  Chips. 

Before  using,  immerse  the  decalcified  chips  in  a  5 
per  cent,  carbolic  acid  solution  for  five  minutes,  then 
rinse  thoroughly  in  physiologic  solution,  place  on  steril- 
ized gauze,  and  dust  lightly  with  iodoform  powder  be- 
fore handing  to  the  surgeon. 

Ligatures  and  Sutures  : 

Catgut,  Xo.  2  and  No.  3. 

Two  surgeon's  needles  for  catgut,  No.  2,  for  muscle 
sutures,  called  buried  sutures. 

Two  large  curved  needles  for  silk  for  tension  sutures. 

Six  glover's  or  surgeon's  needles  for  silkworm  gut. 

Two  glover's  needles  for  horsehair  for  superficial  su- 
tures. 

Dressing,  Etc.  : 
Drainage  tube. 

Boro-salicvlic  acid  powder,  4:1. 
Strips  of  iodoform  gauze,  3  and  8  inches  wide. 
One  pad  of  sterilized  cotton. 
One  yard  of  sterilized  gauze. 
Two  gauze  roller  bandages. 
Two  cotton  roller  bandages. 
Posterior  hollow  splint,  well  padded. 


FOR      THE      OPERATING      ROOM 


171 


Plaster  of  Paris  bandages   and  a  roll   of   absorbent 

cotton  in  reserve. 
A  supply  of  sterilized  gauze  sponges. 
A  supply  of  sterilized  gauze  compresses. 
Twelve  sterilized  towels. 
Three  sterilized  sheets. 
Twelve  sterilized  safety  pins. 
Solutions  : 

lodin,  1/2  to  1  per  cent. 
Lysol,  2  per  cent. 

AMPUTATION  OF  LEG. 

Esmarch's  constrictor. 

Two  scalpels. 

One  amputating  knife. 

One  Catlin  knife   (used  only  for  amputations  below 

the  knee  and  elbow). 
Two  tissue  forceps. 
Twenty-four  hemostatic  forceps. 
One  pair  retractors. 
One  pair  gauze  retractors. 


Gauze  Retractor,  for 
One  Bone. 


Gauze  Retractor,   for 
Two  Bones. 


■Wiiidlei-'s    Anipuluting    Saw. 


Butcher's    Saw. 


Langenbeck's    Metacarpal    Saw. 


FOE      THE      OPERATING      ROOM  173 

One  b one-holding  forceps  (lion  jaw). 

One  bone-cutting  forceps. 

Senn's  periosteal  elevator. 

One  amputation  saw. 

One  pair  scissors,  straight. 

One  pair  scissors,  curved. 

Ligatures : 

Catgut,  Ko.  2  and  No.  3,  ten  inches  long. 

Sutures : 

Two  surgeon's  needles  for  catgut,  ISTo.  2,  for  buried 
sutures. 

Two  surgeon's  needles  for  catgut,  No.  3,  to  suture 
muscles. 

Six  glover's  or  surgeon's  needles  for  silkworm  gut  to 

■   suture  flaps. 

Two  glover's  needles  for  horsehair  for  superficial  su- 
tures. 

Drainage  : 
Fenestrated  rubber  tube. 
Strips  of  iodoform  gauze. 
Strands  of  catgut. 

Dressing,  Etc.  : 

BoTo-salicylic  acid  powder,  4:1. 

Two  yards  sterilized  gauze. 

Large  pad  of  sterilized  absorbent  cotton. 

Two  gauze  roller  bandages. 

A  supply  of  sterilized  gauze  compresses  and  sponges. 

A  well-padded  hollow  posterior  splint. 

Safety  pins. 

Twelve  sterilized  towels. 

Three  sterilized  sheets. 

The  limb  must  be  placed  in  an  elevated  position  at 
an  angle  of  at  least  45  degrees  for  two  days  or  more. 

In  this  or  any  other  case,  when  the  blood  =oaks 
through  the  dressing  and  bandage,  dust  over  the  blood 
stains    with    boro-salicylic    powder    and    apply    a    pad 


Larigenbeck's  Bone  Drills. 


Brainard's  Bone  Drills. 


Brainard's  Bone  Drills. 


FOE     THE      OPERATING      ROOM  175 

of  cotton  and  bandage.  This  will  prevent  the  germs 
from  getting  into  the  wound  through  the  wound  .accre- 
tion in  the  moist  part  of  the  dressing^  which  is  a  good 
culture  medium  for  microbes. 

RESECTION  OF  JOINTS. 

The  requirements  for  this  operation  are  the  same  as 
those  for  the  amputation  of  a  leg,  omitting  the  ampu- 
tating knives  and  adding  the  following: 

Two  chisels. 

Two  gouges. 

Two  long  artery  forceps. 

One  mallet. 

One  Volkmann's  sharp  spoon. 

One  set  of  bone  drills. 

One  scroll  saw. 

Silver  wire. 

Decalcified  bone  chips. 

Iodoform  glycerin  emulsion  and  1  per  cent,  iodin  so- 
lution. 

Thermocautery  (sometimes  used  to  check  bleeding 
from  the  vessels  of  the  bone). 

ARTHRECTOMY. 

(Excision   of  soft  structures   of  joints.) 
Preparation  same  as  for  resection  of  joints. 

TAPPING   AND   INTRAARTICULAR   MEDICATION    OF 
JOINTS. 

The  trocar  should  invariably  be  boiled  in  soda  solu- 
tion before  tapping,  and  the  hands  of  the  sin-geon  and 
the  point  of  puncture  should  be  as  carefully  disinfected 
as  in  the  preparation  for  a  major  operation.  The  small 
trocar  that  accompanies  my  syringe  for  making  intra- 
articular injections  is  very  well  adapted  for  puncturing 
and  evacuating  any  of  the  joints  that  are  ordinarily 
subjected  to  this  method  of  treatment. 


176 


NURSE     S      GUIDE 


To  prepare  tlie  syringe  for  use,  the  rubber  cap  is  re- 
moved from  the  top  of  the  glass  cylinder,  which  is  then 
filled  with  the  fluid  to  be  injected,  after  which  the  cap 
is  replaced.  Before  making  the  puncture  with  the 
needle  or  trocar  the  stop-cock  should  be  opened  and  the 
air  expelled  from  the  rubber  tube  and  canula  or  needle 
by  filling  them  with  the  fluid.  The  scale  on  the  cylin- 
der of  the  S3fringe  is  graduated  in  drams.  A  10  per 
cent,  emulsion  of  iodoform  in  glycerin  is  most  fre- 
quently used  in  this  manner. 


Senn's  Injecting  Syringe. 


Library  of 
American  Medical  AssociATfOd 


CHAPTER  XVIII. 


PLASTER  OF  PARIS  DRESSING. 

Plaster  of  Paris  was  first  "used  as  a  material  for  fixa- 
tion dressing  in  surgery  by  Mathysen  in  1852.  It  ap- 
pears in  the  market  as  an  impalpable,  white  and  highly 
hygroscopic  powder.  It  is  used  in  the  form  of  bandages, 
impregnated  with  the  dry  powder,  and  as  a  cream. 

To  prepare  the  bandages,  take  a  fabric  with  large 
meshes,  such  as  crinolin,  cheese  cloth  or  plain  gauze, 
cut  the  bandages  in  desirable  width  and  length,  roll 
them  firmly  and,  in  unrolling  them,  pass  them  through 
a  heap  of  plaster  on  a  bare  table  and  rub  the  plaster 
well  into  the  meshes  of  the  cloth,  when  they  are  ready 
to  be  rolled  again,  but  this  time  somewhat  loosely  to 
render  them  more  permeable  to  the  entrance  of  water 
when  they  are  to  be  used. 

For  the  fingers,  the  bandages  should  not  be  more  than 
an  inch  in  width ;  for  the  limbs  and  head,  three  to  four 
inches,  and  for  the  body,  from  four  to  six  inches. 

Powder  and  bandages  must  be  kept  in  a  tin  box  to 
guard  against  absorption  of  moisture,  which  ruins  the 
setting  quality  of  the  plaster.  When  the  bandages  are 
to  be  used,  the  skin  is  first  protected  by  a  gauze  or  flan- 
nel bandage.  Immediately  before  using  the  plaster  of 
Paris  bandage  immerse  it  in  a  basin  of  warm  water 
until  it  is  completely  covered.  If  several  bandages  are 
to  be  used  as  many  as  four  to  six  may  be  immersed  at 
the  same  time.  When  all  air  bubbles  have  escaped  from 
the  bandage  take  it  out,  squeeze  it  lightly  and  commence 
the  bandaging.  It  must  never  be  applied  too  tightly, 
for  after  drying,  it  contracts  somewhat.  Eeverses  must 
be  avoided  and,  instead,  make  spiral  turns  to  avoid  un- 
equal pressure. 

With  a  view  of  strengthening  the  bandage  and  to 


178  A    nurse's    guide 

shorten  the  time  necessary  to  support  limbs  or  body  the 
surgeon  often  incorporates  in  the  bandage  a  firm  sup- 
port, and  for  this  purpose  nothing  equals  in  efficiency 
and  ease  of  application  strips  of  wire  gauze  or  screen. 
The  cutting  of  the  metallic  strips  is  done  with  wire- 
cutting  scissors.  Good  plaster  should  set  firmly  in  the 
course  of  half  an  hour  to  an  hour.  If  it  does  not  set 
property,  too  much  water  has  been  used  or  the  plaster 
has  become  moistened  before  its  use.  In  the  latter 
event  the  plaster  must  be  baked  in  an  oven  before  it  is 
used  again  in  the  preparation  of  plaster  of  Paris 
bandages. 


Wire  Gauze. 

The  plaster  of  Paris  cream  is  prepared  in  a  Delf 
dish  by  mixing  equal  quantities  of  plaster  and  cold 
water  under  constant  stirring  until  the  mixture  has  the 
consistence  of  thick  cream.  It  hardens  into  a  compact 
mass  in  about  five  to  ten  minutes  and  must,  therefore, 
be  applied  quickly. 

Plaster  cream  is  often  emplo3'-ed  in  strengthening  the 
plaster  of  Paris  bandage  and  to  render  its  outer  surface 
smooth.  If  the  setting,  either  of  the  bandage  or  the 
cream  is  to  be  hastened,  a  little  salt,  alum  or  cement 
powder  is  added. 

The  plaster  of  Paris  fixation  dressing  is  extensively 
used  in  the  treatment  of  fractures,  fixation  of  joints 
and  immobilization  of  the  spine  and  in  the  treatment 
of  tuberculosis  of  this  part  of  the  skeleton  (Pott's  dis- 
ease). 


FOE     THE      OPERATING      ROOM 


179 


SENN'S    FIXATION    SPLINT    FOR    FRACTURE    OF    THE 
NECK   OF   THE  FEMUR. 

The  patient  receives  a  bath  and  wears  a  pair  of  knit 
drawers.  Having  been  placed  in  Sayre's  suspension  ap- 
paratus, the  splint  is  applied  on  the  injured  side  with 
plaster  of  Paris  bandages  from  toes  to  border  of  ribs,  on 
the  other  side  from  knee  to  same  level. 


Senn's  Fixation  Splint  for  Fracture  of  Femur. 

For  this  purpose  prepare: 

One  roll  of  cotton. 

Wire  gauze. 

Six  three-inch,  and  five  seven-inch  roller  bandages. 

Two  dozen  wide  plaster  of  Paris  bandages  and  a  stool- 
or  box  upon  which  the  patient  may  stand. 

In  more  impacted  fractures  an  anesthetic  is  necessary 
to  enable  the  surgeon  to  effect  immediate  and  perfect 
reposition.  In  these  the  dressing  is  applied  with  pa- 
tient in  dorsal  recumbent  position,  the  pelvis  resting  on 
a  pelvic  support. 

These  patients  require  a  fracture  bed,  which  should 
consist  of  iron  and  measure  G^/.  feet  in  length.  21/)  feet 


180  A    nurse's     guide 

in  height  and  3  feet  in  width  and  be  provided  with  an 
adjustment  to  tighten  the  springs.  It  should  be  fur- 
nished with  a  hard  hair  mattress,  weighing  about  25 
pounds, 

SAYRE'S  JACKET. 

A  plaster  of  Paris  jacket  to  support  the  spine  in  the 
treatment  of : 

Scoliosis :   Lateral  curvature  of  spine. 

Lordosis :   Anterior  curvature  of  spine. 

Kyphosis  :   Posterior  curvature  of  spine. 

The  patient  should  have  a  bath  and  be  attired  in  a 
smooth-fitting  undershirt  and  stockings. 

He  is  suspended  in  Sayre's  extension  apparatus, 
which  is  an  iron  tripod  intended  for  this  purpose.  (See 
page  180.) 

If  the  patient  be  a  small  child  have  him  stand  on  a 
stool. 

Prepare  cotton  to  pad  the  headgear,  two  muslin  pads 
sis  inches  long,  two  inches  wide  and  one  inch  thick. 
These  pads  are  placed  on  each  side  of  the  spine,  a  pad 
of  cotton  to  serve  as  a  dinner-pad.  Tie  a  strip  of  band- 
age around  the  cotton  with  which  to  draw  it  out  when 
the  cast  is  formed.  One  dozen  plaster  of  Paris  band- 
ages from  four  to  six  inches  wide. 


Sayre's    Extension   Apparatus,    with   Tripod, 


CHAPTER  XIX. 


SURGICAL  INSTRUMENTS. 

Surgical  instn^IncIlts  are  the  implements  employed 
by  tlie  sm-geon  in  his  operative  work.  The  construction 
of  instruments  and  their  care  have  been  revolutionized 
since  aseptic  surgery  has  come  into  general  practice. 
On  the  Avhole,  the  size  of  the  instruments  has  been  re- 
duced, and  all  attempts  at  ornamentation  of  handles 
have  been  abolished.  The  surgeons  have  taught  the 
mechanics  to  construct  all  instruments  with  a  view  to 
render  their  sterilization  easv  and  effective.  Modern 
surgical  instruments  are  devoid  of  unnecessary  grooves^ 
notches,  creases  and  sharp  corners.  The  ideal  instru- 
ment is  smooth,  so  that  its  surfaces  can  be  wiped  clean 
with  the  least  difficulty.  The  nurse  who  knows  how  to 
sharpen  the  cutting  instruments  has  mastered  one  of  her 
valuable  accomplishments.  The  nurse  who  knows  the 
names  and  uses  of  the  different  instruments  anticipates 
the  wishes  of  the  surgeon  in  the  operating  room.  The 
surgical  instruments  are  no  longer  housed  in  velvet- 
lined  boxes  or  filthy  pocket  cases.  In  the  operating 
room  the}''  are  kept  in  glass  cases,  and  in  going  from 
place  to  place,  they  are  wrapped  in  aseptic  towels, 
while  canvas  rolls  have  supplanted  the  old-fashioned 
pocket  cases.  j\rany  of  the  instruments  must  be  tested 
before  the  operation,  such  as  the  Paquelin  cautery, 
clamps  and  catch  forceps.  After  the  operation,  the  in- 
struments should  be  carefulh'  cleansed  and  thoroughly 
wiped  before  they  are  laid  away  in  the  glass  case  or 
canvas  roll. 

Sterilization  of  the  instruments  before  an  operation 
can  always  be  relied  upon  by  boiling  in  a  1  per  cent, 
solution  of  carbonate  of  soda  for  fifteen  minutes.  The 
carbonate  of  soda  prevents  the  rusting  of  the  instru- 


POR     THE      OPEEATING      ROOM  183 

ments.  The  dipping  of  an  instrument  into  alcohol 
or  even  pnre  carbolic  acid  can  not  be  depended  upon 
for  rendering  it  surgically  clean.  , 

CARE  OF  INSTRUMENTS  AFTER  OPERATION. 

Collect^  count  and  unlock  instruments.  Cleanse  in 
the  following  manner :  Brush  with  warm  water  to  re- 
move bloody  and  again  with  hot  water  and  potash  soap, 
place  under  hot-water  faucet,  and  allow  the  boiling 
water  to  run  on  them,  dr}^  immediately  with  gauze. 
To  remove  rust  from  instruments,  use  sapolio  sparingly, 
as  otherwise  the  surface  of  the  instrument  will  in  time 
become  injured. 

It  has  been  deemed  advisable  to  select  and  illustrate, 
both  in  and  out  of  the  text,  the  instruments  in  general 
use,  so  that  the  nurse  may  become  conversant  with  their 
names  and  uses. 


184 


A      NUESES      GUIDE 


Tenotome,   Sharp  Pointed. 


^ 


Tenotome,     Blunt    Pointed. 


Senn's  Straight  Bistoury. 


Senn's    Curved    Blunt-pointed   Bistoury. 


^^ssBitea: 


Senn's  Herrnla  Knife. 


POR     THE     OPERATING     ROOil 


18^ 


Liston's 
Amputating  Knife. 


9" 


Senn's  Scalpel. 


Lfston's  Catlln,  Small. 


186 


A      NURSE     S      GUIDE 


General    Operating   Scissors 


Scissors,  Curved  on   the   Plat,    Sharp   Point. 


Cooper's  Scissors,  Curved  on  the  Flat, 
Blunt  Point. 


POR      THE      OPERATING      ROOM  187 


Surgeon's  Full  Curved  Needles. 


Surgeon's  Half-curved  Needles. 


^-^^ 


Keith's   Abdominal   Needles. 


188 


A      NURSE     S      GUIDE 


■■m-..i-l-l.i=^€i 


Glover's  Needles. 


~ 3 


Kelly's    Intestinal    Needles. 


Emmet's  Trocar-point  Needles. 


Senn's   Needle. 


>^ 


Peaslle's  Needle  with  Hagedorn  Point. 


FOR      THE      OPERATING      ROOM  189 


Transfixion  or  Pedicle  Ligature  Carrier. 


Seun's  Aneurysm  Needle. 


Reverdln's  Long-curved  Needle. 


190 


A     \  i:  i;  s  !•:    s     c.  D  t  d  e 


Trnax's    Automatic    Needle    Holder. 


Matliieti's   Needle   Holder. 


Scnn's   Slide-catch    Tissue    Forceps. 


FOR     THE      OPERATING      ROOM  191 


).'\^^^^'^] 


E,    J.    Senn's    Automatic    Forceps. 


Tissue    Forceps. 


Plain    Dressing    Forceps. 


KocLer's   Hemostatic   Forceps 


192 


A      NURSES      GUIDE 


Tail's   Hemostatic   Forceps 


Thornton's   Angular   Bent   Forceps. 


Bulbous   Ligating  Forceps. 


F  0  IJ      THE      OPERATING      ROOM  193 


Eight-inch    Hemostatic    Forceps, 


Bozeman's  Dressing  Forceps. 


Large   Vulseliiim   Forceps. 


194 


A       NUllSES      GUIDE 


Jacob's    Vulsellum    Forceps. 


Senn's  Double  Retractor. 


Volkmann's    Four-pronged    Blunt   Retractors. 


Halsted's    Retractors. 


F  OR      T  II  E  ■    0  I'  E  I{  A  'J'  I  N  O      R  0  0  M  195 


Adam's  Enucleator. 


Kocher's    Director. 


Ordinary  Director  witli  Tongue  Plate. 


Probe  Point  Director  with  Tousrue  I'late. 


196 


A      NUBSE     S      GUIDE 


Minor  Operating  Probes. 


Senn's   Tenaculum. 


Parker's    Amputating    Saw. 


IMPORTANT   TEST   QUESTIONS. 


Write  in  not  less  than  a  hundred  words  the  qualities  whii-li 
a  trained  surgical  nurse  should  possess. 

IIow  would  you  prepare  an  operating  room  in  a  private 
house? 

How  are  hemorrhages   classified? 

Tell  what  you  know  of  the  means  to  be  employed  for  the 
prevention   and   treatment   of  hemorrhage. 

Give  a  brief  explanation  of  the  Metric  Data. 

How  would  you  prepare  and  keep  sterile  normal  salt  solution  ? 

In  what  instances  are  its  uses  indicated? 

Name  and  give  strength  of  the  antiseptic  solutions  in  gen- 
eral use. 

Describe  the  mechanical  and  chemical  disinfection  of  the 
field  of  operation  for  a  laparotomy.  For  an  operation  upon 
the  skull.     Upon  a  mucous  membrane. 

Give  directions   for  the   disinfection   of  hands. 

Describe  the  best  method  of  rendering  and  keeping  rubber 
gloves  aseptic. 

Define  the  terms  sterilization  and  disinfection,  and  describe 
the  processes  for  effecting  each. 

Which  is  the  most  reliable  agent  to  effect  sterilization? 
Why? 

What  are  spores?  Name  diseases  in  which  they  have  proved 
most   refractory. 

Mention  the  different  methods  for  the  sterilization  of  ligature 
and  suturing  material. 

Describe  the  manner  of  preparing  iodized  catgut,  and  give 
formula   of  solution  employed. 

What  is  said  of  the  use  of  antiseptics  in  the  form  of  powder, 
and  under  what  circumstances  are  they  most  frequently  used 
in  practice?     Give  the  methods  for  preparing  iodoform,  salicy- 


198  A      X  U  ];  S  K  '  S      GUIDE 

lalid  and  adhesive  gauze.  How  is  salicylated  col.tou  prepared 
and  kept  aseptic? 

State  briefly  the  preparation  required  and  precautions  to  be 
<ibserved  for  the  administration  of  an  anesthetic. 

\\  hat  are  the  most  important  details  to  be  observed  in 
emergency  work? 

Xame  the  articles  which  the  anesthetizer  should  have  at 
hand. 

describe  methods  of  administering  chloroform  and  ether. 

What  indications  manifest  danger  during  narcosis  ">  How 
are  they  to  be  treated? 

Xame  the  agents  used  for  local  anesthesia.  Explain  metiiods 
of  administration. 

Give  in  detail  the  method  to  be  followed  for  the  thorough 
disinfection  and  sterilization  of  operating  room,  instruments, 
dressings,  etc.,  required  for  a  surgical  operation. 

What  course  of  treatment  would  you  pursue  as  to  diet,  etc., 
in  preparing  a  patient  for  a  laparotomy? 

Explain  the  ordinary  duties  which  devolve  upon  the  senior 
nurse   in   the   operating  room. 

Xame  the  instruments  required  for  abdominal  hysterectomy. 

Give  the  different  methods  for  closing  an  abdominal  incision. 

What  are  buried  sutures?  Specify  the  needles  required  in 
suturing  internal  vascular  organs.     Whj'? 

Describe  the  Paquelin  cautery,  mentioning  cases  in  which 
it  is  used,  the  precautions  to  be  taken  wliilr  handling  it,  and 
its   after-care. 

How  is  the  rectal  tampon  made?     Describe  its  use. 

What  instruments,  ligatures,  dressings,  etc.,  would  you  pre- 
pare  for   the   amputation   of  a    leg? 

Mention  the  instruments  required  for  craniectomj'. 

Name  the  instruments  required  for  tracheotomy. 

In  the  after-treatment  of  the  case,  what  care  devolves  upon 
the  nurse  regarding  the  cleansing  of  the  trachootoniv  tube? 


FOR     THE      OPERATING      ROOM  199 

What  are  the  precautions  to  be  taken  in  the  preparation 
and  use  of  the  intrauterine  douche  tube? 

Define  an  abscess.  In  the  treatment  of  such  why  observe 
aseptic  precautions? 

Describe  the  preparation  and  use  of  Senn's  injecting  syringe. 

Mention  the  various  uses  of  plaster  of  Paris  dressing. 

What  would  you  provide  for  the  application  of  Senn's  fixa- 
tion splint? 

What  treatment  should  a  patient  receive  immediately  after 
a  laparotomy? 

How  would  you  differentiate  between  symptoms  of  hemor- 
rhage and  shock? 

What  means  would  you  employ  to  render  aid  while  await- 
ing the  arrival  of  a  physician? 

Mention  two  other  most  important  wound  complications. 

Give  general  symptoms  by  which  you  would  suspect  their 
onset. 

^Vhat  treatment  is  usually  employed  in  such  cases? 

Xame   the   dift'erent  clinical   thermometers? 

Give  directions  and  explain  reasons  for  rendering  ther- 
mometers aseptic  before  and  after  using. 

In  how  many  ways  may  temperature  be  taken?  ^\Tiat 
variation  in  the  degree  of  temperature  will  result? 

Describe  the  catheter.  What  are  the  precautions  to  be 
taken  in  its  use?  What  directions  are  given  for  sterilizing 
and  keeping  in  an  aseptic  condition? 

What  urinary  tests  should  a  nurse  be  able  to  make? 

How  would  you  proceed  to  make  a  test  for  albumin  ? 


INDEX. 


PAGE 

Abdominal    incisions,    suturing 

of     116 

Abscess,  opening  of 140 

Adenectomy     146 

After-treatment  of   laparotomy 

patients    109 

Air   embolism    .35 

Alcohol      58 

Amputation  of  leg 171 

Anesthesia,    general     84 

method    for    chloroform....    S9 

method   for    ether    99 

preparations    for    84 

preparation   of  patient   for.   84 
preparation    of    room    for .  .    89 

requisites     for     86 

Anesthesia,     local     99 

by   beta-eucain    103 

by    cocain     100 

by    ether    spray    100 

by  ethyl  chlorid    100 

by   methyl   chlorid    lOO 

by    salt    and    ice    99 

by    Schleich's    method 102 

by     tropo-cocain     103 

spinal      103 

Appendectomy     121 

Arthrectomy    175 

Aseptic  adhesive  plaster  strips  73 
Aseptic  tampon    32 

Bacteria,   thermal  death  point  71 

Bag,    obstetric    138 

Breast    excision    147 

Capillary    drainage    78 

Catgut,    ammonium    sulphate.   81 
chromicized  method  of  prep- 
aration        82 

iodized,   method  of  prepara- 
tion         82 

sterilization    of    80 

sterilization,  von  Bergmann's  81 
Catheters,  use  and  care  of .  . . .   43 
Catheterization     after      lapar- 
otomy     Ill 

Cautery,  Paquelin  or  thermo..l59 
Cesarean   operation    136 


PAGE 

Cheiloplasty 141 

Cholecystectomy      124 

Cholecystenterostomy     123 

Cholecystostomy    1 24 

Cholecystotomy    124 

Cocain  as  local  anesthetic.  .  .  .100 

Colostomy,    inguinal     119 

Colporrhaphy     i.gri 

Constrictor,    Esmarch's     30 

Cotton,     borated     77 

salicylated     77 

Craniectomy      162 

Cream,  plaster  of  Paris 178 

Curcuma  tincture,  formula  for  76 
Curettage,    uterine     126 

Data,    metric    system    50 

Dermatoplasty     151 

Diet,     after     laparotomy 110 

before    laparotomy     104 

Disinfection,    sterilization    and  70 

chemical     67 

mechanical     66 

of    field    of    operation 66 

of    hands     62 

of      mucous      cavities      and 

tracts    68 

of    wcrunds     56 

Drainage    and    drainage    mate- 
rial          78 

capillary     78 

Drain,    cigarette     78 

Mikulicz      78 

surface     79 

tubular     78 

Dressings,    for  laparotomy....    72 
sterilization    of     72 

Dressings,    preparation   of  med- 
icated         75 

Adhesive   antiseptic   gauze.  .    76 

Borated    cotton    77 

Carbolized  gauze    76 

Corrosive  sublimate  gauze. .    75 

Iodoform   gauze 75 

Plaster  of  Paris 177 

Salicylated    cotton     77 

Salicylated    gauze     76 


202 


I  N'  D  E  X 


I-AGK 

Dei-matoplasty     151 

Douche,   intrauterine    126 

Empyema,  resection  of  rib  for.  107 

Emulsion,    iodoform     50 

Enema,    liigli    rectal    .3(! 

milk    molasses     llo 

turpentine     113 

Esmarch's  constrictor    29 

Excision    of   maxilla    I(i4 

Eistula,    rectal    15T 

Fixation    splint,    Senns     .  .  .  .179 
Gauze,   preparation   of  medica- 
ted          7(j 

wire    178 

Gastrectomy      118 

Gastro-enterostomy     116 

Gastrectomy      118 

Gloves,    use    and    care    of    rub- 
ber         6'4 

repair   of    65 

Gynecologic    operations     126 

Hands,    disinfection    of 62 

HareliD.     operation     for .  T ...  .1-11 
Hemorrhage,     nrevention     and 

treatment    of     30 

arterial    30 

capillary     30 

venous      30 

Hemorrhoids,    operations    for.  158 

Herniotomy      1 20 

Horsehair,    sterilization    oi.  .  .    sr, 
House,  private,  operating  room 

m     25 

Hysterectomy,   abdominal    ....'35 

vaginal     132 

Hysteromyomectomy     135 

Hysteroi^exy     133 

Heocolostomy    119 

Incisions,      abdominal,      sutur- 
ing'   of    116 

Infusion,    intravenous    34 

Inguinal    colostomy    119 

Injection,  subcutaneous   35 

Instruments  required  for  oper- 
ation   for : 

Abscess,    opening   of    140 

Adenectomy    146 

Amputation    of    leg    171 

Aprpendectomy     121 

Arthreetomy    175 

Cesarean   operation    130 

Cheiloplasty     141 

Cholecystectomy      124 

•    Cholecystenterostomy    123 

Cholecystostomy      124 


I'AGK 

Instruments  required  for  oper- 
ation  for  : 

Choleeystotomy     124 

Circumcision      156 

Colostomy,    inguinal     119 

Colporrhaphy     131 

Craniectomy     162 

Curettage,    uterine 126 

Dermatoplasty     151 

Empyema     167 

Excision    of    maxilla     164 

Fistula      157 

Gasti-ectomy     118 

Gastroenterostomy      116 

Gastrostomy     118 

Harelip     141 

Hemorrhoids      158 

Herniotomy      120 

Hysterectomy,   abdominal.  .  .135 
Hysterectomy,    vaginal    ....132 

Hysteromyomectomy     135 

Hysteropexy    133 

Heocolostomy     119 

Inguinal    colostomy    119 

Joints,    tapping    and    intra- 
articular    medication     of.  175 

Lithotomy,    perineal     152 

Lithotomy,    suprapubic    ....155 

Mammectomy     147 

Maxilla,     excision     of     164 

Myomectomy      136 

Nephrectomy      149 

Nephropexy      148 

Oophorectomy    133 

Perineorrhaphy     129 

Phimosis     156 

Porro   operation    136 

Prostatectomy     156 

Resection  of  joints 175 

Kesection    of    rib    167 

Rhinoplasty     142 

Salpingo-ociphorectomy     .  .  .  .133 

Sequestrotomy     168 

Staphylorrhaphy     141 

Trachelorrhaphy     129 

Tracheotomy      144 

Varicocele 156 

Varicotomy      140 

Injection,    subcutaneous    35 

Instruments,     care     of.     after 

operation      183 

surgical,   list  of 182 

sterilization   of 74,  182 

Iiitravenous    infusion     .......    33 

lodin     solution      57 

Iodoform,    emulsion     59 

gauze,   preparation   of 75 


INDEX 


203 


TAGE 

Jacket,    Sayre's     180 

Joints,    resection    ul'     175 

tapping    and    inti'a-articular 
medication   of    ITTi 

Laparotomy      patients,      after- 
treatment    of     100 

patients,  catheterization  of.ll] 
patients,  diet  after,  for....  110 
patients,   diet  before,   for...  104 

patients,   dressing   for 72 

Leg,    amputation    of    171 

Ligation  of  blood  vessels    ....    31 

Ligature,     indirect     32 

material,     preparation     of..    80 

Lithotomy,    perineal     .  '. 152 

suprapubic      155 

Mammectomy    147 

Maxilla,    excision    of     164 

Metric    data     50 

system       of       weights       and 

measures     52 

Microbes     27 

Mikulicz     drain      78 

Myomectomy      . IS'6 

Nephrectomy      149 

Nephropexy     148 

Nurse,    surgical,   duties   of .  .  .  .    20 

Obstetric    bag     138 

Obstetric    notes     138 

Ointments,    antiseptic 60 

boro-salicylic    00 

chloral  hydrate   60 

Crede    61 

Oophorectomy      133 

Operating      room,      duties      of 

nurse    in    19 

room  in  private  house,  prep- 
aration  of    24 

Paper,      waxed      or      paraffin, 
preparation   of    77 

disinfection    of     78 

Paquelin    or    thermo-cautery .  .1139 

Perineorrhaphy     129 

Peritonitis     112 

Phimosis,     operation    for ir)6 

Physical    sterilization    70 

Physiologic     solution     35 

Plaster-of-Paris  dressing 177 

cream    178 

Pomade,    antiseptic    60 

Porro  operation    136 

Powders,   antiseptic    59 

Powder,   boro-salicylic    00 

iodoform-boric    59 


PAGE 

I'yemia 115 

Rectal     tampon     158 

Resection  of  .ioints 159 

of  rib    167 

Respiration,     artificial 94 

Rhinoplasty      142 

Rib,  resection  for  empyema  ...  167 
Room,    anesthesia,    preparation 

Of 89 

Salicylated    cotlon     77 

gauze   76 

Salpingo-oophorectomy    ]  33 

Salt    solution,    intravenous    in- 

.iectlon    of    34 

uses    and    preparation    of.  .    33 

Sapremia      114 

Sayre's    jacket     180 

Senn's    fixation    splint     179 

Septicemia,       symptoms       and 

treatment    of     114 

Sequestrotomy     168 

Shock,    surgical     ...........  .111 

Skin,    disinfection    of 66 

grafting     151 

Solutions,    antiseptic    in    com- 
mon   use     .53 

Schleich's     102 

Solution,   preparation   and   for- 
mula   of  : 
Acetate    of    aluminum     ....    56 

Bichlorid    of  mercury    53 

Boric    acid     54 

Bromin     57 

Carbolic  acid   54 

Chlorid   of  Zinc    56" 

Todin    57 

Lysol    58 

Physiologic,   or  normal  salt.    58 
Potassium     permanganate.  .    57 

Salicylic    acid     55 

Saline,       normal       salt.       or 

physiologic     58 

Thiersch's    55 

Sponge    holder    106 

Spores,    bacteria     72 

Staphylorrhaphy     141 

Sterilization        and        disinfec- 
tion         70 

Surgical    instruments,    list    of.  182 

Surgical  Nurse,  the    9 

duties    of     13 

Head     105 

Junior     106 

Senior     10(> 

Suturing    of     abdominal     inci- 
sions       116' 


204 


INDEX 


PAGE 

Suturing     materials,     prepara- 
tion   of    SO 

braided   silk    83 

catgut,    ammonium    sulphate 

(Elsberg)      81 

catgut,    chromicized    82 

catgut,        formalin        (Hof- 

meister)    SO 

catgut,    iodized    (Claudius)  .    82 
catgut,       von       Bergntann's 

method     81 

horsehair     83 

silkworm   gut    83 

Sylvester's  method  of  artificial 
respiration     05 

Table  for  operation  in  private 

house    27 

Tampon,  aseptic    32 

rectal    159 

Tapping      and      intra-articular 
medication    of    joints    ...175 

Temperature,     different     ways 

of  taking    48 


PAGE 

Thermometer,  care  and   use  of  48 

Centigrade     46 

Fahrenheit     46 

Reaumur     46 

Trachelorrhaphy     129 

Tracheotomy     144 

Tubular    drains 78 

Urinalysis     39 

Urine,    normal     40 

specific  gravity  of 40 

specific    gravity    of,    how    to 

take    41 

Urine,  tests  of, 

for     albumin     42 

for  blood  and  pus    42 

for    sugar    42 

Uterine    curettage    126 

Vaginal    hysterectomy     132 

Varicocele    156 

Vai'icotomy     149 

Weights  and  measures,   metric 

system     52 

Wire    gauze     178 

Wound    complications    Ill 


Date 


Due 


^*«^"-.;m,c 


,</ 


^6 


A  "u™s  guide  for  the  operating  room  / 


2002195500 


:isi,: 


,r.  -i 


L   i   ■ 


